Provider Demographics
NPI:1225014657
Name:CAROLINA RADIOLOGY ASSOCIATES LLC
Entity Type:Organization
Organization Name:CAROLINA RADIOLOGY ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:B
Authorized Official - Middle Name:ED
Authorized Official - Last Name:SHELLEY
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:843-692-0570
Mailing Address - Street 1:PO BOX 678904
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75267-8904
Mailing Address - Country:US
Mailing Address - Phone:843-467-2676
Mailing Address - Fax:843-497-9566
Practice Address - Street 1:300 SINGLETON RIDGE RD
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-9142
Practice Address - Country:US
Practice Address - Phone:843-238-8660
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89016MMMedicaid
NC890177BMedicaid
SCGP1429Medicaid
SCCC5487OtherRAILROAD MEDICARE
NC89016MHMedicaid
NC890157JMedicaid
SCGP1849Medicaid
NC89016MGMedicaid
NC5900383Medicaid
NC89016MJMedicaid
NC89016NCMedicaid
SC601119OtherFIRST CHOICE
NC89016MFMedicaid
SCGP4104Medicaid
SC=========OtherBCBS--809 82ND PKWY
SC=========002OtherBCBS-300 SINGLETON RIDGE
NC89016NCMedicaid
SC5472Medicare ID - Type Unspecified