Basic Information
| Provider Information | |||||||||
| NPI: | 1366622789 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JACKSONVILLE RADIOLOGY ASSOCIATES PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2555 PONCE DE LEON BLVD | ||||||||
| Address2: | 4TH FLOOR | ||||||||
| City: | CORAL GABLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331346010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3057025135 | ||||||||
| FaxNumber: | 3054412144 | ||||||||
| Practice Location | |||||||||
| Address1: | 4201 BELFORT RD | ||||||||
| Address2: | ATTN RADIOLOGY DEPARTMENT | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322161431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042963700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2007 | ||||||||
| LastUpdateDate: | 07/02/2008 | ||||||||
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| AuthorizedOfficialLastName: | WALKER | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3057025135 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.