Provider Demographics
NPI:1881617843
Name:BEAUFORT MEDICAL IMAGING INC
Entity type:Organization
Organization Name:BEAUFORT MEDICAL IMAGING INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:CLYDE
Authorized Official - Middle Name:P
Authorized Official - Last Name:BLALOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-522-5200
Mailing Address - Street 1:5700 SOUTHWYCK BLVD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43614-1509
Mailing Address - Country:US
Mailing Address - Phone:800-288-8325
Mailing Address - Fax:419-866-5453
Practice Address - Street 1:955 RIBAUT RD
Practice Address - Street 2:
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29902-5441
Practice Address - Country:US
Practice Address - Phone:843-522-5130
Practice Address - Fax:843-522-5538
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCCK8953OtherRAILROAD MEDICARE
SCGP3666Medicaid
SCGP3666Medicaid