Provider Demographics
NPI:1437332947
Name:SOUTH ALABAMA DIAGNOSTIC IMAGING PC
Entity Type:Organization
Organization Name:SOUTH ALABAMA DIAGNOSTIC IMAGING PC
Other - Org Name:JOHN C TOMBERLIN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:RADIOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:C
Authorized Official - Last Name:TOMBERLIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:334-684-7156
Mailing Address - Street 1:PO BOX 1928
Mailing Address - Street 2:
Mailing Address - City:BAINBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:39818-1928
Mailing Address - Country:US
Mailing Address - Phone:334-684-3655
Mailing Address - Fax:334-684-3312
Practice Address - Street 1:2600 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:BONIFAY
Practice Address - State:FL
Practice Address - Zip Code:32425-4264
Practice Address - Country:US
Practice Address - Phone:334-684-7156
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-07
Last Update Date:2019-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME604382085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL047944603Medicaid
FL047944604Medicaid
FL047944602Medicaid
FLK2337AMedicare PIN