1548257041 NPI number — JACKSONVILLE BEACHES MEDICAL IMAGING INC

Table of content: (NPI 1548257041)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548257041 NPI number — JACKSONVILLE BEACHES MEDICAL IMAGING INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JACKSONVILLE BEACHES MEDICAL IMAGING INC
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:
Provider Other Organization Name Type Code:
6
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:
1548257041
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/02/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2700 RIVERSIDE AVE
Provider Second Line Business Mailing Address:
SUITE 1
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32205-8275
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-381-9994
Provider Business Mailing Address Fax Number:
904-389-6866

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2700 RIVERSIDE AVE
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32205-8275
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-381-9994
Provider Business Practice Location Address Fax Number:
904-389-6866
Provider Enumeration Date:
09/30/2005

Additional Information

Authorized Official

Authorized Official Last Name:
BLAESE
Authorized Official First Name:
CATHY
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF OPERATING OFFICER
Authorized Official Telephone Number:
904-241-7772

Provider Taxonomy Codes

  • Taxonomy code: 261QR0200X , with the licence number:  HCCR1430 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1840590 . This is a "1ST HEALTH PROVIDER #" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 2000441 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 470001666 . This is a "RR MEDICARE PROVIDER #" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: V2622 . This is a "BCBS FL PIN #" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 147878902 . This is a "1ST HEALTH W/C #" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 7842141 . This is a "AETNA PROVIDER #" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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