Provider Demographics
NPI:1013165810
Name:MOBILE DIAGNOSTIC IMAGING, LLC
Entity Type:Organization
Organization Name:MOBILE DIAGNOSTIC IMAGING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:F
Authorized Official - Last Name:WEES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-266-4908
Mailing Address - Street 1:PO BOX 2461
Mailing Address - Street 2:
Mailing Address - City:WINTERSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43953-0461
Mailing Address - Country:US
Mailing Address - Phone:740-266-4908
Mailing Address - Fax:740-266-4908
Practice Address - Street 1:403 CANTON RD
Practice Address - Street 2:
Practice Address - City:WINTERSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43953-3907
Practice Address - Country:US
Practice Address - Phone:740-266-4908
Practice Address - Fax:740-264-4376
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-04
Last Update Date:2008-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
001705585OtherBLUE CROSS BLUE SHIELD
WV6803009000Medicaid
OH07873168Medicaid
OHID01062Medicare PIN
001705585OtherBLUE CROSS BLUE SHIELD