Basic Information
| Provider Information | |||||||||
| NPI: | 1992758056 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MORRISTOWN IMAGING CONSULTANTS, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 51863 | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379501863 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8655316070 | ||||||||
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| Practice Location | |||||||||
| Address1: | 908 W 4TH NORTH ST | ||||||||
| Address2: | |||||||||
| City: | MORRISTOWN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378143894 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4233182478 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 07/13/2007 | ||||||||
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| AuthorizedOfficialLastName: | LEE | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF MANAGER/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4233182478 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 3724408 | 05 | TN | MEDICAID |