Basic Information
| Provider Information | |||||||||
| NPI: | 1184682494 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BECKER | ||||||||
| FirstName: | VINCENT | ||||||||
| MiddleName: | GERARD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1301 SUNSET DR | ||||||||
| Address2: | STE 3 | ||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376047906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4239264966 | ||||||||
| FaxNumber: | 4239261823 | ||||||||
| Practice Location | |||||||||
| Address1: | 1301 SUNSET DR | ||||||||
| Address2: | STE 3 | ||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376047906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4239264966 | ||||||||
| FaxNumber: | 4239261823 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 34969 | TN | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 64031164 | 01 | KY | KENTUCKY MEDICAID | OTHER | 7239875 | 01 | VA | VIRGINIA MEDICAID | OTHER | 3862458 | 05 | TN | MEDICAID | 4007341 | 01 | TN | BCBS | OTHER | 89064NJ | 01 | NC | NORTH CAROLINA MEDICAID | OTHER |