Basic Information
Provider Information | |||||||||
NPI: | 1629434394 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MIDDLE TENNESSEE IMAGING, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PREMIER RADIOLOGY MOBILE DIAGNOSTICS | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 75 REMITTANCE DR DEPT 6244 | ||||||||
Address2: |   | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 606756244 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6158516003 | ||||||||
FaxNumber: | 6159488488 | ||||||||
Practice Location | |||||||||
Address1: | 28 WHITE BRIDGE RD | ||||||||
Address2: | SUITE 314 | ||||||||
City: | NASHVILLE | ||||||||
State: | TN | ||||||||
PostalCode: | 372051499 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6159866040 | ||||||||
FaxNumber: | 6159866041 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/11/2016 | ||||||||
LastUpdateDate: | 03/30/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CASSIN | ||||||||
AuthorizedOfficialFirstName: | NAOMI | ||||||||
AuthorizedOfficialMiddleName: | M | ||||||||
AuthorizedOfficialTitleorPosition: | AVP, PROVIDER ENROLLMENT | ||||||||
AuthorizedOfficialTelephone: | 3127248477 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/30/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0208X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Radiology, Mobile |
No ID Information.