Basic Information
Provider Information | |||||||||
NPI: | 1851339634 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HARNEY | ||||||||
FirstName: | IANTHA | ||||||||
MiddleName: | LUCILLE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | ALLTON | ||||||||
OtherFirstName: | IANTHA | ||||||||
OtherMiddleName: | LUCILLE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 3024 BUSINESS PARK CIR | ||||||||
Address2: |   | ||||||||
City: | GOODLETTSVILLE | ||||||||
State: | TN | ||||||||
PostalCode: | 370723132 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6158516033 | ||||||||
FaxNumber: | 6158512018 | ||||||||
Practice Location | |||||||||
Address1: | 3024 BUSINESS PARK CIR | ||||||||
Address2: |   | ||||||||
City: | GOODLETTSVILLE | ||||||||
State: | TN | ||||||||
PostalCode: | 370723132 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6158516033 | ||||||||
FaxNumber: | 6158512018 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/03/2006 | ||||||||
LastUpdateDate: | 11/30/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 41015 | TN | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | 3338876 | 05 | TN |   | MEDICAID | 4133808 | 01 | TN | BCBS | OTHER | 4291492 | 01 | TN | BCBS - MTI | OTHER | 1509268 | 01 | TN | MEDICAID - TN | OTHER | 3338877 | 05 | TN |   | MEDICAID | 4133805 | 01 | TN | BCBS | OTHER | 1509268 | 05 | TN |   | MEDICAID | 4200560 | 01 | TN | BCBS TN | OTHER | 7100039390 | 05 | KY |   | MEDICAID |