1093773384 NPI number — MECKLENBURG DIAGNOSTIC IMAGING LLC

Table of content: (NPI 1093773384)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093773384 NPI number — MECKLENBURG DIAGNOSTIC IMAGING LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MECKLENBURG DIAGNOSTIC IMAGING 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:
NOVANT HEALTH IMAGING SOUTHPARK
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:
1093773384
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/19/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 603543
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28260-3543
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-393-5600
Provider Business Mailing Address Fax Number:
770-300-9018

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6324 FAIRVIEW RD
Provider Second Line Business Practice Location Address:
SUITE 120 A
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28210-3200
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-362-8444
Provider Business Practice Location Address Fax Number:
704-362-3557
Provider Enumeration Date:
05/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GARDNER
Authorized Official First Name:
GEOFFREY
Authorized Official Middle Name:
K.
Authorized Official Title or Position:
SVP FINANCE AND REVENUE CYCLE
Authorized Official Telephone Number:
336-718-2078

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: SL0083 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01514 . This is a "BCBS NC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: NPB300 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 153718700 . This is a "DOL" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: P00315955 . This is a "MEDICARE RR" identifier . This identifiers is of the category "OTHER".
  • Identifier: 6901514 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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