Provider Demographics
NPI:1730130345
Name:PREMIER DIAGNOSTIC IMAGING, LLC
Entity Type:Organization
Organization Name:PREMIER DIAGNOSTIC IMAGING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:M
Authorized Official - Last Name:HUMPHREY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:931-528-2443
Mailing Address - Street 1:PO BOX 1502
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38503-1502
Mailing Address - Country:US
Mailing Address - Phone:931-528-1800
Mailing Address - Fax:931-528-1488
Practice Address - Street 1:315 N WASHINGTON AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-2603
Practice Address - Country:US
Practice Address - Phone:931-528-1800
Practice Address - Fax:931-528-2443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD6278174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3193998Medicaid
TN3029804Medicaid
TN3193466Medicaid
TN3037577Medicaid
TN3134538OtherTN BCBS
TN3134539OtherTN BCBS
TN3156107OtherTN BCBS
TN3134540OtherTN BCBS
TN3035368Medicaid
TN3134541OtherTN BCBS
TN3029800Medicare ID - Type Unspecified
TNB59517Medicare UPIN
TN3037571Medicare ID - Type Unspecified
TN3193465Medicare ID - Type Unspecified
TN3193998Medicaid
TN3134541OtherTN BCBS
TNA99916Medicare UPIN
TN3134539OtherTN BCBS
TNB00078Medicare UPIN
TN3193466Medicaid