MEDICARE: SHADES MOUNTAIN IMAGING PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0202X	Diagnostic Radiology Physician

General Provider Information

NPI Number	:	1033157185
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHADES MOUNTAIN IMAGING PC

Provider Business Mailing Address
First Line	:	2000A SOUTHBRIDGE PKWY
Second Line	:	STE 300
City	:	BIRMINGHAM
State	:	AL
Zip	:	35209-7704
Country	:	US
Telephone Number	:	205-871-4274
Fax Number	:	205-871-4301

Provider Business Practice Location Address
First Line	:	502 MONTGOMERY HWY
Second Line	:	STE 101
City	:	VESTAVIA HILLS
State	:	AL
Zip	:	35216-1862
Country	:	US
Telephone Number	:	205-823-0882
Fax Number	:	205-823-0872

Authorized Official
Title or Position	:	PRESIDENT
Name	:	CHARLES MICHAEL MEAD
Credential	:	MD
Telephone Number	:	205-823-0882

Provider Enumeration Date	:	06/02/2006
Last Update Date	:	08/22/2020

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