Provider Demographics
NPI:1841215621
Name:BROOKWOOD DIAGNOSTIC IMAGING CENTER, LLC
Entity Type:Organization
Organization Name:BROOKWOOD DIAGNOSTIC IMAGING CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR DIR, REG IMAGING OPS, TENET
Authorized Official - Prefix:MR
Authorized Official - First Name:DALE
Authorized Official - Middle Name:
Authorized Official - Last Name:SKRNICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-893-6942
Mailing Address - Street 1:PO BOX 740799
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-0799
Mailing Address - Country:US
Mailing Address - Phone:205-877-2453
Mailing Address - Fax:205-871-0534
Practice Address - Street 1:513 BROOKWOOD BLVD STE 100
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35209-6878
Practice Address - Country:US
Practice Address - Phone:205-877-1000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2016-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL11009261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
183095OtherFDA#
148669OtherUMWA
33915OtherHEALTH PARTNER
16-10435OtherUHC
AL000055370Medicare PIN