Organization
TALLAHASSEE DIAG IMAGING CTR LTD
Active
Organization
TALLAHASSEE DIAG IMAGING CTR LTD
Active
Other names
Tallahassee Diagnostic Imaging LTD
Organization subpart
No
Provider details
NPI number
Authorized official
JOHN R DETELICH (CEO)
(850) 671-6412
Entity
Organization
Contact information
Practice address
1600 PHILLIPS RD, TALLAHASSEE, FL 32308-5304
(850) 878-4127
(850) 878-9729
Mailing address
PO BOX 21348, TAMPA, FL 33622-1348
(850) 878-4127
(850) 942-4155
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
—
—
2471C3401X
Computed Tomography Radiologic Technologist
—
—
2471M1202X
Magnetic Resonance Imaging Radiologic Technologist
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
062730500
—
FL
05
—
062730502
—
FL
05
—
062730503
—
FL
01
—
300038358C
GA MEDICAID
GA
01
—
98956
BC BS FL
FL
01
—
CL1403
RR MEDICARE
FL
01
—
V3052
BCBS
FL
01
—
V3053
BCBS
FL
01
—
V3054
BCBS
FL
Enumeration date
05/11/2006
Last updated
05/19/2017
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