Basic Information
Provider Information | |||||||||
NPI: | 1568449932 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ADVANCED MEDICAL IMAGING CENTER, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ADVANCED MEDICAL IMAGING | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 292921 | ||||||||
Address2: |   | ||||||||
City: | TAMPA | ||||||||
State: | FL | ||||||||
PostalCode: | 336872921 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8136752498 | ||||||||
FaxNumber: | 8139710818 | ||||||||
Practice Location | |||||||||
Address1: | 525 S LAWRENCE ST | ||||||||
Address2: |   | ||||||||
City: | MONTGOMERY | ||||||||
State: | AL | ||||||||
PostalCode: | 361044611 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3342627226 | ||||||||
FaxNumber: | 3342612641 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/28/2005 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WRIGHT | ||||||||
AuthorizedOfficialFirstName: | GARY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
AuthorizedOfficialTelephone: | 8136752439 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0200X | 10857 | AL | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Radiology |
No ID Information.