Provider Demographics
NPI:1093762759
Name:MOUNTAIN EMPIRE RADIOLOGY INC PC
Entity Type:Organization
Organization Name:MOUNTAIN EMPIRE RADIOLOGY INC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:C
Authorized Official - Last Name:LUCAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-926-4966
Mailing Address - Street 1:1301 SUNSET DR
Mailing Address - Street 2:STE 3
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-7906
Mailing Address - Country:US
Mailing Address - Phone:423-926-4966
Mailing Address - Fax:423-926-1823
Practice Address - Street 1:1301 SUNSET DR
Practice Address - Street 2:STE 3
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-7906
Practice Address - Country:US
Practice Address - Phone:423-926-4966
Practice Address - Fax:423-926-1823
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8902245OtherNORTH CAROLINA MEDICAID
TN3378531Medicaid
KY65927972OtherKENTUCKY MEDICAID
KY65927972OtherKENTUCKY MEDICAID