Provider Demographics
NPI:1083613699
Name:IMAGING CENTER OF COLUMBUS, LLC
Entity Type:Organization
Organization Name:IMAGING CENTER OF COLUMBUS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:G
Authorized Official - Last Name:HOWARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-291-9161
Mailing Address - Street 1:2526 5TH ST N
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MS
Mailing Address - Zip Code:39705-2019
Mailing Address - Country:US
Mailing Address - Phone:662-328-8402
Mailing Address - Fax:662-328-1554
Practice Address - Street 1:2526 5TH ST N
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39705-2019
Practice Address - Country:US
Practice Address - Phone:662-328-8402
Practice Address - Fax:662-328-1554
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-15
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes293D00000XLaboratoriesPhysiological LaboratoryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009986505Medicaid
MS06325773Medicaid
MSP00115067Medicare PIN
AL009986505Medicaid