Basic Information
| Provider Information | |||||||||
| NPI: | 1841746393 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ASSOCIATION OF UNIVERSITY RADIOLOGISTS, PC | ||||||||
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| OtherOrganizationName: | UNIVERSITY RADIOLOGY PC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5401 KINGSTON PIKE | ||||||||
| Address2: | STE 540 | ||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379195022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8655847376 | ||||||||
| FaxNumber: | 8655848938 | ||||||||
| Practice Location | |||||||||
| Address1: | 1420 TUSCULUM BLVD | ||||||||
| Address2: | |||||||||
| City: | GREENEVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 377454279 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237875000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2016 | ||||||||
| LastUpdateDate: | 12/18/2017 | ||||||||
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| AuthorizedOfficialLastName: | LANGENBERG | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8655847376 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0204X | TN | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085R0202X | TN | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 3386745 | 05 | TN | MEDICAID |