Basic Information
| Provider Information | |||||||||
| NPI: | 1487121703 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVANCD DIAGNOSTIC IMAGING, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3024 BUSINESS PARK CIR | ||||||||
| Address2: | |||||||||
| City: | GOODLETTSVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370723132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6158516033 | ||||||||
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| Practice Location | |||||||||
| Address1: | 200 CREEKSIDE DR | ||||||||
| Address2: | |||||||||
| City: | DICKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370552176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6158516033 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2018 | ||||||||
| LastUpdateDate: | 10/24/2018 | ||||||||
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| AuthorizedOfficialLastName: | FENTON | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 6158516033 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ADVANCD DIAGNOSTIC IMAGING, PC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3372986 | 05 | TN | MEDICAID |