Organization
RADIOLOGY ASSOCIATES OF TALLAHASSEE PA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JOHN R DETELICH (CEO)
(850) 878-4127
Entity
Organization
Contact information
Practice address
1300 MICCOSUKEE RD, TALLAHASSEE, FL 32308-5054
(850) 431-1155
Mailing address
PO BOX 1678, TALLAHASSEE, FL 32302-1678
(850) 878-4127
Taxonomy
Speciality
Code
Description
License number
State
2085R0202X
Diagnostic Radiology Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
00060
BLUE CROSS OF FLORIDA
FL
05
—
053297501
—
FL
05
—
053297504
—
FL
05
—
053297505
—
FL
05
—
300037169A
—
GA
01
—
CA6404
RR MEDICARE
FL
Enumeration date
07/27/2015
Last updated
07/27/2015
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