Provider Demographics
NPI:1043285539
Name:CLARKSVILLE IMAGING CENTER LLC
Entity Type:Organization
Organization Name:CLARKSVILLE IMAGING CENTER LLC
Other - Org Name:CLARKSVILLE IMAGING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:GABRIEL
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:STARACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-851-6033
Mailing Address - Street 1:PO BOX 249
Mailing Address - Street 2:
Mailing Address - City:GOODLETTSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37070-0249
Mailing Address - Country:US
Mailing Address - Phone:615-851-6033
Mailing Address - Fax:615-994-8488
Practice Address - Street 1:2320 WILMA RUDOLPH BLVD
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37040-5821
Practice Address - Country:US
Practice Address - Phone:931-245-6736
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-20
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
4034353OtherBCBS
TN3376506Medicaid
CK9332OtherRAILROAD MEDICARE
CK9332OtherRAILROAD MEDICARE