Healthcare Provider Details

I. General information

NPI: 1639469547
Provider Name (Legal Business Name): ENT IMAGING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2011
Last Update Date: 04/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 10TH AVE S SUITE 502
BIRMINGHAM AL
35205-1200
US

IV. Provider business mailing address

2700 10TH AVE S SUITE 502
BIRMINGHAM AL
35205-1200
US

V. Phone/Fax

Practice location:
  • Phone: 205-933-2952
  • Fax: 205-933-5893
Mailing address:
  • Phone: 205-933-2952
  • Fax: 205-933-5893

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YX0901X
TaxonomyOtology & Neurotology Physician
License Number16561
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number10997
License Number StateAL

VIII. Authorized Official

Name: DR. LEV H BRAGG
Title or Position: PRESIDENT
Credential: M.D.
Phone: 205-933-2952