Provider Demographics
NPI:1518918481
Name:PRESBYTERIAN IMAGING CENTERS LLC
Entity Type:Organization
Organization Name:PRESBYTERIAN IMAGING CENTERS LLC
Other - Org Name:PRESBYTERIAN IMAGING CENTER UNIVERSITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EVP CFO
Authorized Official - Prefix:
Authorized Official - First Name:FRED
Authorized Official - Middle Name:M
Authorized Official - Last Name:HARGETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-384-5184
Mailing Address - Street 1:2085 FRONTIS PLAZA BLVD
Mailing Address - Street 2:
Mailing Address - City:WINSTON-SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-5614
Mailing Address - Country:US
Mailing Address - Phone:336-277-7226
Mailing Address - Fax:336-277-9795
Practice Address - Street 1:8401 MEDICAL PLAZA DR
Practice Address - Street 2:STE 110
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-8797
Practice Address - Country:US
Practice Address - Phone:704-384-1580
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-15
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2085R0202X, 261QR0200X
NC293D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No293D00000XLaboratoriesPhysiological Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5917808Medicaid
P00471051OtherRAILROAD MEDICARE
NC615320705OtherNC DOL
16-42368OtherUHC
NC615320705OtherNC DOL