Basic Information
| Provider Information | |||||||||
| NPI: | 1780279471 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVANCED 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: | 225 N WILLOW AVE | ||||||||
| Address2: | |||||||||
| City: | COOKEVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 385012335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9313728227 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/04/2021 | ||||||||
| LastUpdateDate: | 03/04/2021 | ||||||||
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| AuthorizedOfficialLastName: | FENTON | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 6158516033 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ADVANCED DIAGNOSTIC IMAGING, PC | ||||||||
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| NPICertificationDate: | 03/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.