Provider Demographics
NPI:1043988983
Name:ADVANCED DIAGNOSTIC IMAGING, PC
Entity Type:Organization
Organization Name:ADVANCED DIAGNOSTIC IMAGING, PC
Other - Org Name:PREMIER FOOT & ANKLE CENTERS OF TENNESSEE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:FENTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-854-3409
Mailing Address - Street 1:3024 BUSINESS PARK CIR
Mailing Address - Street 2:
Mailing Address - City:GOODLETTSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37072-3132
Mailing Address - Country:US
Mailing Address - Phone:615-239-2018
Mailing Address - Fax:615-851-2018
Practice Address - Street 1:1428 SPARTA ST STE 4
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:TN
Practice Address - Zip Code:37110-1365
Practice Address - Country:US
Practice Address - Phone:931-507-3668
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-04
Last Update Date:2021-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment