Basic Information
| Provider Information | |||||||||
| NPI: | 1720102361 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VIDALIA IMAGING ASSOCIATES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 13220 | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314160220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123558188 | ||||||||
| FaxNumber: | 9123566970 | ||||||||
| Practice Location | |||||||||
| Address1: | 1703 MEADOWS LN | ||||||||
| Address2: | |||||||||
| City: | VIDALIA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 304748915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9125378921 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2007 | ||||||||
| LastUpdateDate: | 07/10/2007 | ||||||||
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| AuthorizedOfficialLastName: | SPARKS | ||||||||
| AuthorizedOfficialFirstName: | BRENDA | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9123558267 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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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.