Basic Information
| Provider Information | |||||||||
| NPI: | 1508807249 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | REIDSVILLE IMAGING CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 16983 | ||||||||
| Address2: | |||||||||
| City: | CHAPEL HILL | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275166983 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199676646 | ||||||||
| FaxNumber: | 9199676647 | ||||||||
| Practice Location | |||||||||
| Address1: | 2509 RICHARDSON DR | ||||||||
| Address2: | SUITE A | ||||||||
| City: | REIDSVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 273205901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3363495899 | ||||||||
| FaxNumber: | 3363495995 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2006 | ||||||||
| LastUpdateDate: | 01/16/2009 | ||||||||
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| AuthorizedOfficialLastName: | EVELAND | ||||||||
| AuthorizedOfficialFirstName: | RAYMOND | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 3362025593 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085B0100X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Body Imaging |
ID Information
| ID | Type | State | Issuer | Description | 017YH | 01 | NC | BLUE CROSS/BLUE SHIELD | OTHER | 5904292 | 05 | NC | MEDICAID |