1336164532 NPI number — MCMINN MEDICAL IMAGING, PC

Table of content: (NPI 1770711004)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336164532 NPI number — MCMINN MEDICAL IMAGING, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MCMINN MEDICAL IMAGING, PC
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:
Provider Other Organization Name Type Code:
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:
1336164532
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/08/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 843
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATHENS
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37371-0843
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-744-3256
Provider Business Mailing Address Fax Number:
423-746-1484

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1114 W MADISON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ATHENS
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37303-4150
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-744-3256
Provider Business Practice Location Address Fax Number:
423-746-1484
Provider Enumeration Date:
07/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LEMINGS
Authorized Official First Name:
STEPHEN
Authorized Official Middle Name:
Authorized Official Title or Position:
RADIOLOGIST; PRESIDENT
Authorized Official Telephone Number:
423-744-3256

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  MD10736 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2006167 . This is a "BLUECROSS BLUESHEILD TN" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 3383885 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3383885 . This is a "MEDICARE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: CD8301 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 018478600 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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