Organization
SOUTHEAST RADIOLOGY ASSOCIATES PL
Active
Organization
SOUTHEAST RADIOLOGY ASSOCIATES PL
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JOHN R DETELICH (CEO)
(850) 878-4127
Entity
Organization
Contact information
Practice address
340 NW COMMERCE DR, LAKE CITY, FL 32055-4709
(386) 719-9000
Mailing address
PO BOX 2293, LAKE CITY, FL 32056-2293
(386) 752-1316
Taxonomy
Speciality
Code
Description
License number
State
2085B0100X
Body Imaging Physician
—
—
2085N0700X
Neuroradiology Physician
—
—
2085N0904X
Nuclear Radiology Physician
—
—
2085P0229X
Pediatric Radiology Physician
—
—
2085R0202X
Diagnostic Radiology Physician
Primary
—
—
2085R0204X
Vascular & Interventional Radiology Physician
—
—
2085U0001X
Diagnostic Ultrasound Physician
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
97561
BCBS
FL
Enumeration date
05/31/2006
Last updated
10/17/2007
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