1598751810 NPI number — DR. GARY T. PODGORSKI MD

Table of content: DR. GARY T. PODGORSKI MD (NPI 1598751810)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598751810 NPI number — DR. GARY T. PODGORSKI MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PODGORSKI
Provider First Name:
GARY
Provider Middle Name:
T.
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1598751810
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/21/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1224 TROTWOOD AVE
Provider Second Line Business Mailing Address:
SOUTHERN RADIOLOGY ASSOCIATES, PLL
Provider Business Mailing Address City Name:
COLUMBIA
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38401-4802
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
931-647-5034
Provider Business Mailing Address Fax Number:
931-552-6663

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1224 TROTWOOD AVE
Provider Second Line Business Practice Location Address:
SOUTHERN RADIOLOGY ASSOCIATES, PLL
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38401-4802
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
931-647-5034
Provider Business Practice Location Address Fax Number:
931-552-6663
Provider Enumeration Date:
09/22/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  92212 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: MD15386 , 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: 87131 . This is a "BLUE CROSS PROVIDER NUMBE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 3050164 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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