Basic Information
| Provider Information | |||||||||
| NPI: | 1316043524 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MURFREESBORO RADIOLOGY AND NUCLEAR MED CONSULTANTS, PLLC | ||||||||
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| OtherOrganizationName: | MID-STATE RADIOLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2330 UTAH AVE # 200 | ||||||||
| Address2: | |||||||||
| City: | EL SEGUNDO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902454817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152959431 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1700 MEDICAL CENTER PKWY | ||||||||
| Address2: | |||||||||
| City: | MURFREESBORO | ||||||||
| State: | TN | ||||||||
| PostalCode: | 371292245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153964100 | ||||||||
| FaxNumber: | 9315526663 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2006 | ||||||||
| LastUpdateDate: | 12/30/2021 | ||||||||
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| AuthorizedOfficialLastName: | CASSIN | ||||||||
| AuthorizedOfficialFirstName: | NAOMI | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | ASSOC. VP, PROVIDER ENROLLMENT | ||||||||
| AuthorizedOfficialTelephone: | 3127248477 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0204X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085R0202X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | CG6538 | 01 | TN | TN RAILROAD MEDICARE | OTHER | 3376120 | 05 | TN | MEDICAID |