Basic Information
| Provider Information | |||||||||
| NPI: | 1972615581 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVANCED IMAGING OF GADSDEN LLC | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 820 SOUTH 4TH STREET | ||||||||
| Address2: | |||||||||
| City: | GADSDEN | ||||||||
| State: | AL | ||||||||
| PostalCode: | 359015223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2565490008 | ||||||||
| FaxNumber: | 2565490401 | ||||||||
| Practice Location | |||||||||
| Address1: | 820 S 4TH STREET | ||||||||
| Address2: | |||||||||
| City: | GADSDEN | ||||||||
| State: | AL | ||||||||
| PostalCode: | 359015223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2565490008 | ||||||||
| FaxNumber: | 2565490401 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 06/21/2018 | ||||||||
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| 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 | 529921610 | 05 | AL | MEDICAID | DC6981 | 01 | AL | MEDICARE RAILROAD | OTHER | 113978 | 05 | AL | MEDICAID |