Provider Demographics
NPI:1508824814
Name:SOUTH CAROLINA DIAGNOST IMAGING INC
Entity Type:Organization
Organization Name:SOUTH CAROLINA DIAGNOST IMAGING INC
Other - Org Name:SUMMERVILLE MRI & IMAGING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:SCHAEFER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-300-0101
Mailing Address - Street 1:PO BOX 933548
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31193-3548
Mailing Address - Country:US
Mailing Address - Phone:770-300-0101
Mailing Address - Fax:770-300-0429
Practice Address - Street 1:4340 LADSON ROAD
Practice Address - Street 2:SUITE C
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29485
Practice Address - Country:US
Practice Address - Phone:770-300-0101
Practice Address - Fax:770-300-0429
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-03
Last Update Date:2008-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSL0053Medicaid
SC470001385OtherRAILROAD MEDICARE
SC=========003OtherTRICARE
SC=========003OtherBLUE CHOICE IDTF
SCSL0053Medicaid
SCQ327980001Medicare PIN