Basic Information
| Provider Information | |||||||||
| NPI: | 1821623638 | ||||||||
| 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 | ||||||||
| FaxNumber: | 6158512018 | ||||||||
| Practice Location | |||||||||
| Address1: | 179 HANCOCK ST STE 300 | ||||||||
| Address2: | |||||||||
| City: | GALLATIN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370666347 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6152208788 | ||||||||
| FaxNumber: | 6152208688 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2020 | ||||||||
| LastUpdateDate: | 03/12/2020 | ||||||||
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| AuthorizedOfficialLastName: | FENTON | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 6158516033 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | Y | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
No ID Information.