Provider Demographics
NPI:1962468256
Name:SOUTHERN IMAGING SPECIALISTS, LLC
Entity Type:Organization
Organization Name:SOUTHERN IMAGING SPECIALISTS, 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 1:465 SAINT LUKES DR
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36117-7107
Mailing Address - Country:US
Mailing Address - Phone:334-279-8370
Mailing Address - Fax:334-279-8572
Practice Address - Street 1:465 SAINT LUKES DR
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36117-7107
Practice Address - Country:US
Practice Address - Phone:334-279-8370
Practice Address - Fax:334-279-8572
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-25
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
AL051557566Medicaid
ALP00357962Medicare PIN
AL051557566Medicaid