Provider Demographics
NPI:1699062422
Name:ST JOSEPH'S DIAGNOSTIC CENTER LLC
Entity type:Organization
Organization Name:ST JOSEPH'S DIAGNOSTIC CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TAMBLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:CUBERO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-281-9390
Mailing Address - Street 1:2995 DREW STREET
Mailing Address - Street 2:EAST BLDG 2ND FLOOR
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33759
Mailing Address - Country:US
Mailing Address - Phone:727-281-9390
Mailing Address - Fax:
Practice Address - Street 1:12780 RACE TRACK RD
Practice Address - Street 2:SUITE 100
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33626-1397
Practice Address - Country:US
Practice Address - Phone:813-749-7810
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-30
Last Update Date:2019-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL061048801Medicaid
FL97779Medicare PIN