1730130345 NPI number — PREMIER DIAGNOSTIC IMAGING, LLC

Table of content: (NPI 1730130345)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730130345 NPI number — PREMIER DIAGNOSTIC IMAGING, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREMIER 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:
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:
1730130345
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/17/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1502
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COOKEVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38503-1502
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
931-528-1800
Provider Business Mailing Address Fax Number:
931-528-1488

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
315 N WASHINGTON AVE
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
COOKEVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38501-2603
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
931-528-1800
Provider Business Practice Location Address Fax Number:
931-528-2443
Provider Enumeration Date:
05/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HUMPHREY
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PROVIDER/PRESIDENT
Authorized Official Telephone Number:
931-528-2443

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  MD6278 , 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: 3193998 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3029804 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3193466 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3037577 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3134538 . This is a "TN BCBS" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 3134539 . This is a "TN BCBS" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 3156107 . This is a "TN BCBS" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 3134540 . This is a "TN BCBS" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 3035368 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3134541 . This is a "TN BCBS" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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