Basic Information
| Provider Information | |||||||||
| NPI: | 1073158481 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BLUEWATER RADIOLOGY, PLLC | ||||||||
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| OtherOrganizationName: | BLUEWATER DIAGNOSTIC IMAGING | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 242848 | ||||||||
| Address2: | |||||||||
| City: | MONTGOMERY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 361242848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3342709914 | ||||||||
| FaxNumber: | 3342703195 | ||||||||
| Practice Location | |||||||||
| Address1: | 4536 E HIGHWAY 20 | ||||||||
| Address2: | |||||||||
| City: | NICEVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325789755 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8507296747 | ||||||||
| FaxNumber: | 8507297279 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2019 | ||||||||
| LastUpdateDate: | 12/07/2020 | ||||||||
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| AuthorizedOfficialLastName: | BARNETT | ||||||||
| AuthorizedOfficialFirstName: | ROSS | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8507296747 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 12/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.