1558342998 NPI number — ST JOSEPHS DIAGNOSTIC CENTER LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558342998 NPI number — ST JOSEPHS DIAGNOSTIC CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST JOSEPHS DIAGNOSTIC CENTER LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
BAYCARE OUTPATIENT IMAGING
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1558342998
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/17/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2995 DREW STREET
Provider Second Line Business Mailing Address:
EAST BLDG 2ND FLOOR
Provider Business Mailing Address City Name:
CLEARWATER
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33759
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-281-9390
Provider Business Mailing Address Fax Number:
813-635-2613

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3003 W DR MLK JR BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TAMPA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33607-6307
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-870-4826
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/11/2005

Additional Information

Authorized Official

Authorized Official Last Name:
CUBERO
Authorized Official First Name:
TAMBLYN
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
727-281-9390

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: V2334 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: V2332 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 061048800 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: V2333 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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