Provider Demographics
NPI:1710081013
Name:ANGEL WILLIAMSON IMAGING CENTER P A
Entity Type:Organization
Organization Name:ANGEL WILLIAMSON IMAGING CENTER P A
Other - Org Name:PENSACOLA DIAGNOSTIC CENTER AND BREAST CLINIC ANGEL WILLIAMSON WOMENS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:WILLIAMSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-476-1161
Mailing Address - Street 1:5120 BAYOU BLVD
Mailing Address - Street 2:SUITE 9
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32503
Mailing Address - Country:US
Mailing Address - Phone:850-476-1161
Mailing Address - Fax:850-476-1550
Practice Address - Street 1:5120 BAYOU BLVD
Practice Address - Street 2:SUITE 9
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503
Practice Address - Country:US
Practice Address - Phone:850-476-1161
Practice Address - Fax:850-476-1550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-08
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLCA2365OtherRAILROAD MEDICARE
FLV2944OtherBCBS FL
FL373112000Medicaid
FLCA2365OtherRAILROAD MEDICARE