Provider Demographics
NPI:1760530208
Name:LAKE CITY - KINGSTREE RADIOLOGY, PC
Entity Type:Organization
Organization Name:LAKE CITY - KINGSTREE RADIOLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BERT
Authorized Official - Middle Name:L
Authorized Official - Last Name:BOOKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-374-6171
Mailing Address - Street 1:3328 GUESS RD
Mailing Address - Street 2:SUITE 2A
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27705-2158
Mailing Address - Country:US
Mailing Address - Phone:919-620-5700
Mailing Address - Fax:919-620-3632
Practice Address - Street 1:258 N RON MCNAIR BLVD
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:SC
Practice Address - Zip Code:29560-2462
Practice Address - Country:US
Practice Address - Phone:843-374-6171
Practice Address - Fax:843-374-6133
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCA4139OtherRAIL ROAD MEDICARE
SCGP3037Medicaid
SCA4139OtherRAIL ROAD MEDICARE