Healthcare Provider Details

I. General information

NPI: 1881617843
Provider Name (Legal Business Name): BEAUFORT MEDICAL IMAGING INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 11/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

955 RIBAUT RD
BEAUFORT SC
29902-5441
US

IV. Provider business mailing address

5700 SOUTHWYCK BLVD
TOLEDO OH
43614-1509
US

V. Phone/Fax

Practice location:
  • Phone: 843-522-5130
  • Fax: 843-522-5538
Mailing address:
  • Phone: 800-288-8325
  • Fax: 419-866-5453

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: CLYDE P. BLALOCK
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 843-522-5200