Basic Information
| Provider Information | |||||||||
| NPI: | 1598712085 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DIAGNOSTIC IMAGING CONSULTANTS INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 DODDS AVE | ||||||||
| Address2: | |||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374043911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4236299783 | ||||||||
| FaxNumber: | 4236983622 | ||||||||
| Practice Location | |||||||||
| Address1: | 2525 DESALES AVE | ||||||||
| Address2: | |||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374041161 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234954430 | ||||||||
| FaxNumber: | 4234956179 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2006 | ||||||||
| LastUpdateDate: | 01/30/2008 | ||||||||
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| AuthorizedOfficialLastName: | KRETZMEIER | ||||||||
| AuthorizedOfficialFirstName: | JENNY | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 4236299783 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | TN | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 3376193 | 05 | TN | MEDICAID |