Basic Information
Provider Information | |||||||||
NPI: | 1629221510 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ADVANCED IMAGING OF ALABAMA LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 820 SOUTH 4TH STREET | ||||||||
Address2: |   | ||||||||
City: | GADSDEN | ||||||||
State: | AL | ||||||||
PostalCode: | 359015223 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2565490008 | ||||||||
FaxNumber: | 2565490401 | ||||||||
Practice Location | |||||||||
Address1: | 1699 GOLDEN SPRINGS RD | ||||||||
Address2: |   | ||||||||
City: | ANNISTON | ||||||||
State: | AL | ||||||||
PostalCode: | 362077097 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2568350835 | ||||||||
FaxNumber: | 2565490401 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/23/2008 | ||||||||
LastUpdateDate: | 09/26/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HAGER | ||||||||
AuthorizedOfficialFirstName: | KENNON | ||||||||
AuthorizedOfficialMiddleName: | H | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER/PHYSICIAN | ||||||||
AuthorizedOfficialTelephone: | 2565490008 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 17729 | AL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | 510-49315 | 01 | AL | BC/BS OF AL | OTHER | 113978 | 05 | AL |   | MEDICAID |