Provider Demographics
NPI:1508829029
Name:BURLINGTON RADIOLOGICAL ASSOCIATES
Entity Type:Organization
Organization Name:BURLINGTON RADIOLOGICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:G
Authorized Official - Last Name:WALL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:336-538-7000
Mailing Address - Street 1:PO BOX 11546
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37939-1546
Mailing Address - Country:US
Mailing Address - Phone:865-766-8800
Mailing Address - Fax:865-766-8874
Practice Address - Street 1:1240 HUFFMAN MILL RD
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27215-8700
Practice Address - Country:US
Practice Address - Phone:336-538-7861
Practice Address - Fax:336-538-7547
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-07
Last Update Date:2022-07-21
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
NC8901145Medicaid
NC01145OtherBCBS OF NC
NCCK6815Medicare PIN
NC01145OtherBCBS OF NC
NCCC6420Medicare PIN