1225014657 NPI number — CAROLINA RADIOLOGY ASSOCIATES LLC

Table of content: (NPI 1225014657)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225014657 NPI number — CAROLINA RADIOLOGY ASSOCIATES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CAROLINA RADIOLOGY ASSOCIATES 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:
1225014657
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 678904
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75267-8904
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-467-2676
Provider Business Mailing Address Fax Number:
843-497-9566

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 SINGLETON RIDGE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CONWAY
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29526-9142
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-238-8660
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/18/2005

Additional Information

Authorized Official

Authorized Official Last Name:
SHELLEY
Authorized Official First Name:
B
Authorized Official Middle Name:
ED
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
843-692-0570

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2085R0204X , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 89016MM , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 890177B , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: GP1429 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: CC5487 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 89016MH , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 890157J , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: GP1849 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 89016MG , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5900383 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 89016MJ , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 89016NC , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 601119 . This is a "FIRST CHOICE" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 89016MF , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: GP4104 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 016965900 . 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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