Provider Demographics
NPI:1104874387
Name:JACKSONVILLE DIAGNOSTIC IMAGING LLC
Entity type:Organization
Organization Name:JACKSONVILLE DIAGNOSTIC IMAGING LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SVP FINANCE AND REVENUE CYCLE
Authorized Official - Prefix:MR
Authorized Official - First Name:GEOFFREY
Authorized Official - Middle Name:K
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-718-2078
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 1:3606 HENDERSON DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-5217
Practice Address - Country:US
Practice Address - Phone:910-937-7226
Practice Address - Fax:910-937-0064
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-04
Last Update Date:2024-03-19
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
NC89014UNMedicaid
NC014UNOtherBCBS NC
NC101136600OtherDOL
NCP00107621OtherMEDICARE RAILROAD
NC101136600OtherDOL
NC101136600OtherDOL