Provider Demographics
NPI:1740757764
Name:ADVANCED DIAGNOSTIC IMAGING, PC
Entity Type:Organization
Organization Name:ADVANCED DIAGNOSTIC IMAGING, PC
Other - Org Name:COVENANT MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:FENTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-851-6033
Mailing Address - Street 1:3024 BUSINESS PARK CIR
Mailing Address - Street 2:
Mailing Address - City:GOODLETTSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37072-3132
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2340 FAIRVIEW BOULEVARD
Practice Address - Street 2:SUITE 600D
Practice Address - City:FAIRVIEW
Practice Address - State:TN
Practice Address - Zip Code:37062
Practice Address - Country:US
Practice Address - Phone:615-441-6140
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ADVANCED DIAGNOSTIC IMAGING, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-10-29
Last Update Date:2020-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty