Basic Information
| Provider Information | |||||||||
| NPI: | 1225014657 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CAROLINA RADIOLOGY ASSOCIATES LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 678904 | ||||||||
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| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752678904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8434672676 | ||||||||
| FaxNumber: | 8434979566 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 SINGLETON RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | CONWAY | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295269142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8432388660 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2005 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | SHELLEY | ||||||||
| AuthorizedOfficialFirstName: | B | ||||||||
| AuthorizedOfficialMiddleName: | ED | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8436920570 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0204X | SC | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085R0202X | SC | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 89016MM | 05 | NC | MEDICAID | 890177B | 05 | NC | MEDICAID | GP1429 | 05 | SC | MEDICAID | CC5487 | 01 | SC | RAILROAD MEDICARE | OTHER | 89016MH | 05 | NC | MEDICAID | 890157J | 05 | NC | MEDICAID | GP1849 | 05 | SC | MEDICAID | 89016MG | 05 | NC | MEDICAID | 5900383 | 05 | NC | MEDICAID | 89016MJ | 05 | NC | MEDICAID | 89016NC | 05 | NC | MEDICAID | 601119 | 01 | SC | FIRST CHOICE | OTHER | 89016MF | 05 | NC | MEDICAID | GP4104 | 05 | SC | MEDICAID |