1043285539 NPI number — CLARKSVILLE IMAGING CENTER LLC

Table of content: (NPI 1043285539)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043285539 NPI number — CLARKSVILLE IMAGING CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CLARKSVILLE IMAGING CENTER LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CLARKSVILLE IMAGING CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043285539
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/27/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 249
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GOODLETTSVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37070-0249
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-851-6033
Provider Business Mailing Address Fax Number:
615-994-8488

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2320 WILMA RUDOLPH BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLARKSVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37040-5821
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
931-245-6736
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/20/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
STARACE
Authorized Official First Name:
GABRIEL
Authorized Official Middle Name:
EDWARD
Authorized Official Title or Position:
AUTHORIZED OFFICIAL
Authorized Official Telephone Number:
615-851-6033

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4034353 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3376506 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: CK9332 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".