Provider Demographics
NPI:1336529197
Name:TWINCITY MEDICAL MOBILE DIAGNOSTICS
Entity Type:Organization
Organization Name:TWINCITY MEDICAL MOBILE DIAGNOSTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:O
Authorized Official - Last Name:CORNWALL
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:336-816-6800
Mailing Address - Street 1:163 STRATFORD CT
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-1836
Mailing Address - Country:US
Mailing Address - Phone:336-816-6800
Mailing Address - Fax:888-507-6778
Practice Address - Street 1:163 STRATFORD CT
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103
Practice Address - Country:US
Practice Address - Phone:336-816-6800
Practice Address - Fax:888-507-6778
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-05
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
NC21159261QR0208X, 335V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No261QR0208XAmbulatory Health Care FacilitiesClinic/CenterRadiology, MobileGroup - Single Specialty
No335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging SupplierGroup - Multi-Specialty