=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033110358
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALPHA IMAGING, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/09/2005
-----------------------------------------------------
Last Update Date | 06/10/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1499 FAIR RD
-----------------------------------------------------
City | STATESBORO
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30458-1683
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-486-1000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 348
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31902-0348
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-850-1441
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. THAD D LONG
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 912-486-1620
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------