MEDICARE: SOUTH ALABAMA DIAGNOSTIC IMAGING PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0202X	Diagnostic Radiology Physician	ME60438	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1437332947
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH ALABAMA DIAGNOSTIC IMAGING PC

Provider Business Mailing Address
First Line	:	PO BOX 1928
Second Line	:
City	:	BAINBRIDGE
State	:	GA
Zip	:	39818-1928
Country	:	US
Telephone Number	:	334-684-3655
Fax Number	:	334-684-3312

Provider Business Practice Location Address
First Line	:	2600 HOSPITAL DR
Second Line	:
City	:	BONIFAY
State	:	FL
Zip	:	32425-4264
Country	:	US
Telephone Number	:	334-684-7156
Fax Number	:

Authorized Official
Title or Position	:	RADIOLOGIST
Name	:	DR. JOHN C TOMBERLIN
Credential	:	MD
Telephone Number	:	334-684-7156

Provider Enumeration Date	:	12/07/2007
Last Update Date	:	06/14/2019

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