1407003510 NPI number — PRESBYTERIAN IMAGING CENTERS LLC

Table of content: (NPI 1407003510)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407003510 NPI number — PRESBYTERIAN IMAGING CENTERS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRESBYTERIAN IMAGING CENTERS 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:
1407003510
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/13/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 60598
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28260-0598
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:
2000 WELLNESS BOULEVARD
Provider Second Line Business Practice Location Address:
STE 110
Provider Business Practice Location Address City Name:
MONROE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28110-7764
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-316-1180
Provider Business Practice Location Address Fax Number:
704-316-1181
Provider Enumeration Date:
08/20/2008

Additional Information

Authorized Official

Authorized Official Last Name:
HARGETT
Authorized Official First Name:
FRED
Authorized Official Middle Name:
M
Authorized Official Title or Position:
EVP CFO
Authorized Official Telephone Number:
704-384-5184

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: P00187889 . This is a "RR MEDICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 2881790E . This is a "PTAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: NPB425 . This is a "SC MEDICAID" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 5917804 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 615320700 . This is a "DOL" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 016M6 . This is a "BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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