1235278961 NPI number — ADVANCED DIAGNOSTIC IMAGING PC

Table of content: SLATEN CREW BURRIS (NPI 1487343026)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235278961 NPI number — ADVANCED DIAGNOSTIC IMAGING PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANCED DIAGNOSTIC 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:
6
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:
1235278961
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/30/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1120 PROFESSIONAL BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EVANSVILLE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47714-8000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-471-7086
Provider Business Mailing Address Fax Number:
812-471-3381

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
328 N 2ND ST STE 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VINCENNES
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47591-1353
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-882-8252
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
COLLINS
Authorized Official First Name:
DEBBIE
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
812-475-0765

Provider Taxonomy Codes

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

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

  • Identifier: 200181650A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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