Healthcare Provider Details

I. General information

NPI: 1962510958
Provider Name (Legal Business Name): THE IMAGING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 08/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

818 ST. SEBASTIAN WAY SUITE 100
AUGUSTA GA
30901
US

IV. Provider business mailing address

1125 TROUPE ST
AUGUSTA GA
30904-4480
US

V. Phone/Fax

Practice location:
  • Phone: 706-722-3574
  • Fax: 706-731-5289
Mailing address:
  • Phone: 706-737-4575
  • Fax: 706-731-5289

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number014725
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code2085D0003X
TaxonomyDiagnostic Neuroimaging (Radiology) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code261QR0206X
TaxonomyMammography Clinic/Center
License Number
License Number State
# 9
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. HUEY G. BULLOCK
Title or Position: MD/PARTNER/MEDICAL DIRECTOR
Credential: MD
Phone: 706-737-4575