Provider Demographics
NPI:1487121703
Name:ADVANCD DIAGNOSTIC IMAGING, PC
Entity type:Organization
Organization Name:ADVANCD DIAGNOSTIC IMAGING, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:FENTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-851-6033
Mailing Address - Street 1:3024 BUSINESS PARK CIR
Mailing Address - Street 2:
Mailing Address - City:GOODLETTSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37072-3132
Mailing Address - Country:US
Mailing Address - Phone:615-851-6033
Mailing Address - Fax:
Practice Address - Street 1:200 CREEKSIDE DR
Practice Address - Street 2:
Practice Address - City:DICKSON
Practice Address - State:TN
Practice Address - Zip Code:37055-2176
Practice Address - Country:US
Practice Address - Phone:615-851-6033
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ADVANCD DIAGNOSTIC IMAGING, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-10-24
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3372986Medicaid