Provider Demographics
NPI:1619158862
Name:MOBILE MEDICAL IMAGING LLC
Entity Type:Organization
Organization Name:MOBILE MEDICAL IMAGING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:STEVEN
Authorized Official - Last Name:JACOBUS
Authorized Official - Suffix:
Authorized Official - Credentials:RT(ARRT)
Authorized Official - Phone:803-917-2988
Mailing Address - Street 1:1127 OLD RD
Mailing Address - Street 2:
Mailing Address - City:CHAPIN
Mailing Address - State:SC
Mailing Address - Zip Code:29036-8512
Mailing Address - Country:US
Mailing Address - Phone:803-917-2988
Mailing Address - Fax:803-781-0077
Practice Address - Street 1:1127 OLD RD
Practice Address - Street 2:
Practice Address - City:CHAPIN
Practice Address - State:SC
Practice Address - Zip Code:29036-8512
Practice Address - Country:US
Practice Address - Phone:803-917-2988
Practice Address - Fax:803-781-0077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-16
Last Update Date:2016-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC498018Medicaid
SC300005574OtherTRAVELERS MEDICARE RAILRO
SCQ26672Medicare UPIN
SC498018Medicaid