Healthcare Provider Details

I. General information

NPI: 1124000856
Provider Name (Legal Business Name): SOUTH BALDWIN DIAGNOSTIC IMAGINE ASSOCIATES, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2005
Last Update Date: 03/19/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1613 N MCKENZIE ST
FOLEY AL
36535-2247
US

IV. Provider business mailing address

PO BOX 160550
ALTAMONTE SPRINGS FL
32716-0550
US

V. Phone/Fax

Practice location:
  • Phone: 251-949-1513
  • Fax: 251-476-5460
Mailing address:
  • Phone: 713-559-6929
  • Fax: 713-559-6928

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: MARK R CONNELL
Title or Position: AUTHORIZED OFFICIAL
Credential: M.D.
Phone: 251-949-3513