Provider Demographics
NPI:1962450155
Name:MECKLENBURG DIAGNOSTIC IMAGING LLC
Entity Type:Organization
Organization Name:MECKLENBURG DIAGNOSTIC IMAGING LLC
Other - Org Name:NORTH CAROLINA DIAGNOSTIC IMAGING - MONROE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:SCHAEFER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-300-0101
Mailing Address - Street 1:PO BOX 933393
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31193-0001
Mailing Address - Country:US
Mailing Address - Phone:866-659-1211
Mailing Address - Fax:336-774-1751
Practice Address - Street 1:1309 E SUNSET DR
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28112-4324
Practice Address - Country:US
Practice Address - Phone:704-225-8674
Practice Address - Fax:704-225-7226
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-04
Last Update Date:2009-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNPB299Medicaid
NC5902728Medicaid
NC017M8OtherBCBS NC
P00315955OtherMEDICARE RR
SCSL0074Medicaid
NC153718702OtherDOL
SCSL0074Medicaid
NC017M8OtherBCBS NC