=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790146140
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARIANNA IMAGING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/13/2016
-----------------------------------------------------
Last Update Date | 03/13/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4250 HOSPITAL DR
-----------------------------------------------------
City | MARIANNA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32446-1917
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-718-2580
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 609 N BAY DR
-----------------------------------------------------
City | LYNN HAVEN
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32444-3026
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. WILLIAM SCOTT CAMPBELL JR.
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 850-381-3847
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | ME51689
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------