Provider Demographics
NPI:1073605762
Name:LAUDERDALE RADIOLOGY GROUP
Entity Type:Organization
Organization Name:LAUDERDALE RADIOLOGY GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RADIOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:VONHERRMANN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:256-768-8168
Mailing Address - Street 1:201 S COURT STREET
Mailing Address - Street 2:SUITE 500
Mailing Address - City:FLORENCE
Mailing Address - State:AL
Mailing Address - Zip Code:35630
Mailing Address - Country:US
Mailing Address - Phone:256-768-8168
Mailing Address - Fax:256-768-8322
Practice Address - Street 1:1701 VETERANS DRIVE
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:AL
Practice Address - Zip Code:35630
Practice Address - Country:US
Practice Address - Phone:256-768-8168
Practice Address - Fax:256-768-8322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-29
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00006072247100000X
ALD0137247100000X
AL00023957247100000X
AL00016553247100000X
ALMD.26676247100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51519728OtherBC
AL009934433Medicaid
AL51540375OtherBC
AL51039506OtherBC
AL009934439Medicaid
AL528202620Medicaid
AL009934437Medicaid
AL51039286OtherBC
AL009934434Medicaid
AL51507878OtherBC
AL51543162OtherBC EAST BILYEU