Provider Demographics
NPI:1093773384
Name:MECKLENBURG DIAGNOSTIC IMAGING LLC
Entity Type:Organization
Organization Name:MECKLENBURG DIAGNOSTIC IMAGING LLC
Other - Org Name:NOVANT HEALTH IMAGING SOUTHPARK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SVP FINANCE AND REVENUE CYCLE
Authorized Official - Prefix:MR
Authorized Official - First Name:GEOFFREY
Authorized Official - Middle Name:K
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-718-2078
Mailing Address - Street 1:PO BOX 603543
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-3543
Mailing Address - Country:US
Mailing Address - Phone:678-393-5600
Mailing Address - Fax:770-300-9018
Practice Address - Street 1:6324 FAIRVIEW RD
Practice Address - Street 2:SUITE 120 A
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-3200
Practice Address - Country:US
Practice Address - Phone:704-362-8444
Practice Address - Fax:704-362-3557
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-03
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSL0083Medicaid
NC01514OtherBCBS NC
SCNPB300Medicaid
NC153718700OtherDOL
P00315955OtherMEDICARE RR
NC6901514Medicaid
SCSL0083Medicaid
NC153718700OtherDOL