Basic Information
| Provider Information | |||||||||
| NPI: | 1831169382 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RIVER RADIOLOGY, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 SIGNATURE PLACE | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37087 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6154442320 | ||||||||
| FaxNumber: | 6154493163 | ||||||||
| Practice Location | |||||||||
| Address1: | 5002 CROSSINGS CIRCLE | ||||||||
| Address2: | |||||||||
| City: | MT. JULIET | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6154442320 | ||||||||
| FaxNumber: | 6154493163 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | DISMUKES | ||||||||
| AuthorizedOfficialFirstName: | DEBBIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRACTICE ADMIN | ||||||||
| AuthorizedOfficialTelephone: | 6154442320 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | TN | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 3731806 | 05 | TN | MEDICAID |