Basic Information
| Provider Information | |||||||||
| NPI: | 1013482660 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ADVANCED DIAGNOSTIC IMAGING, PC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ORTHOPAEDIC SPECIALISTS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3024 BUSINESS PARK CIR | ||||||||
| Address2: | |||||||||
| City: | GOODLETTSVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370723132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6158516033 | ||||||||
| FaxNumber: | 6158512018 | ||||||||
| Practice Location | |||||||||
| Address1: | 425 HENSLEE DR | ||||||||
| Address2: | |||||||||
| City: | DICKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370552166 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153758287 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2018 | ||||||||
| LastUpdateDate: | 10/15/2018 | ||||||||
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| AuthorizedOfficialLastName: | FENTON | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 6158516033 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 335E00000X | N | Suppliers | Prosthetic/Orthotic Supplier | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.