Provider Demographics
NPI:1609978170
Name:PROVIDENCE DIAGNOSTIC IMAGING, INC.
Entity Type:Organization
Organization Name:PROVIDENCE DIAGNOSTIC IMAGING, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:E
Authorized Official - Last Name:BLACKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:413-748-9200
Mailing Address - Street 1:271 CAREW ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01104-2377
Mailing Address - Country:US
Mailing Address - Phone:413-748-9200
Mailing Address - Fax:
Practice Address - Street 1:271 CAREW ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01104-2377
Practice Address - Country:US
Practice Address - Phone:413-748-9200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-03
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody ImagingGroup - Multi-Specialty
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiologyGroup - Multi-Specialty
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear RadiologyGroup - Multi-Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic UltrasoundGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
102940700OtherUS DEPARTMENT OF LABOR
MA98133101OtherNETWORK HEALTH
MA000000025268OtherBMC HEALTHNET PLAN
MA755228OtherTUFTS
CT003126358Medicaid
1601748OtherEVERCARE
774327OtherCONNECTICARE
MA9776559Medicaid
CA7920OtherRAILROAD MEDICARE
MA783230OtherAETNA/US HEALTHCARE
MAM16237OtherBLUE CROSS/BLUE SHIELD
MA783230OtherAETNA/US HEALTHCARE