1265480446 NPI number — MECKLENBURG DIAGNOSTIC IMAGING LLC

Table of content: (NPI 1265480446)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265480446 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:
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:
1265480446
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/15/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 933393
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31193-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
866-659-1211
Provider Business Mailing Address Fax Number:
336-774-1751

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3723 UNION RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GASTONIA
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28056-8044
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-854-3933
Provider Business Practice Location Address Fax Number:
704-854-3995
Provider Enumeration Date:
05/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SCHAEFER
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
J
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
770-300-0101

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: 017M7 . This is a "BCBS NC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 153718701 . 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: SL0082 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5902729 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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