Provider Demographics
NPI:1538162334
Name:TENNESSEE IMAGING ALLIANCE LLC
Entity type:Organization
Organization Name:TENNESSEE IMAGING ALLIANCE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:DOUGLAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-477-1815
Mailing Address - Street 1:2628 N MOUNT JULIET RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT JULIET
Mailing Address - State:TN
Mailing Address - Zip Code:37122-8015
Mailing Address - Country:US
Mailing Address - Phone:615-758-2606
Mailing Address - Fax:615-758-2604
Practice Address - Street 1:2628 N MOUNT JULIET RD
Practice Address - Street 2:
Practice Address - City:MOUNT JULIET
Practice Address - State:TN
Practice Address - Zip Code:37122-8015
Practice Address - Country:US
Practice Address - Phone:615-758-2606
Practice Address - Fax:615-758-2604
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TENNESSEE IMAGING ALLIANCE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-05-24
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0208XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mobile
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3791297Medicaid
TN3791297Medicare PIN