Basic Information
| Provider Information | |||||||||
| NPI: | 1992755680 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNION MEDICAL SERVICES LLC | ||||||||
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| OtherOrganizationName: | ATRIUM HEALTH IMAGING INDIAN TRAIL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 E MOREHEAD ST STE 300 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282022742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043347800 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6030 W HIGHWAY 74 | ||||||||
| Address2: | SUITE C | ||||||||
| City: | INDIAN TRAIL | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280793468 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7042462999 | ||||||||
| FaxNumber: | 7047700501 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 10/27/2021 | ||||||||
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| AuthorizedOfficialLastName: | KREPSHAW | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP RADIOLOGY | ||||||||
| AuthorizedOfficialTelephone: | 7043625391 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 293D00000X | N | Laboratories | Physiological Laboratory | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | NPB186 | 05 | SC | MEDICAID |