Basic Information
Provider Information | |||||||||
NPI: | 1447210109 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LECONTE RADIOLOGY PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1445 | ||||||||
Address2: |   | ||||||||
City: | INDIANAPOLIS | ||||||||
State: | IN | ||||||||
PostalCode: | 462061445 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8655882928 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 907 E LAMAR ALEXANDER PKWY | ||||||||
Address2: |   | ||||||||
City: | MARYVILLE | ||||||||
State: | TN | ||||||||
PostalCode: | 378045015 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8659775567 | ||||||||
FaxNumber: | 8659804962 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/27/2006 | ||||||||
LastUpdateDate: | 07/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | NIETHAMMER | ||||||||
AuthorizedOfficialFirstName: | JOHN | ||||||||
AuthorizedOfficialMiddleName: | G | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 8659775567 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: | III | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: | 11/22/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X |   | TN | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | 65935397 | 05 | KY |   | MEDICAID | CJ2946 | 01 | TN | RR MCARE | OTHER | 3373480 | 05 | TN |   | MEDICAID | TN0100 | 01 | TN | JOHN DEERE | OTHER |