Provider Demographics
NPI:1124000856
Name:SOUTH BALDWIN DIAGNOSTIC IMAGINE ASSOCIATES, P.C.
Entity type:Organization
Organization Name:SOUTH BALDWIN DIAGNOSTIC IMAGINE ASSOCIATES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:R
Authorized Official - Last Name:CONNELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:251-949-3513
Mailing Address - Street 1:PO BOX 160550
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32716-0550
Mailing Address - Country:US
Mailing Address - Phone:713-559-6929
Mailing Address - Fax:713-559-6928
Practice Address - Street 1:1613 N MCKENZIE ST
Practice Address - Street 2:
Practice Address - City:FOLEY
Practice Address - State:AL
Practice Address - Zip Code:36535-2247
Practice Address - Country:US
Practice Address - Phone:251-949-1513
Practice Address - Fax:251-476-5460
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-17
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
E880Medicare PIN