Provider Demographics
NPI:1841294691
Name:MEDICAL DIAGNOSTIC SERVICES,LLC
Entity type:Organization
Organization Name:MEDICAL DIAGNOSTIC SERVICES,LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:M
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-863-0827
Mailing Address - Street 1:2005 VENTURE PARK
Mailing Address - Street 2:STE 21
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-1098
Mailing Address - Country:US
Mailing Address - Phone:423-863-0827
Mailing Address - Fax:
Practice Address - Street 1:2005 VENTURE PARK
Practice Address - Street 2:STE 21
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-1098
Practice Address - Country:US
Practice Address - Phone:423-863-0827
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN335V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3409803Medicaid
TN3403932OtherTRICARE FOR LIFE
TN3403932AMedicaid
TN4056127OtherBCBS OF TENNESSEE
TN3403932OtherHUMANA GOLD PLUS
NC3409803Medicaid
TN3403932OtherHUMANA GOLD PLUS
TN3403932OtherTRICARE FOR LIFE
TN3403932Medicare ID - Type UnspecifiedCIGNA MEDICARE TN