Basic Information
| Provider Information | |||||||||
| NPI: | 1114551132 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LEBANON PET SCAN CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 440149 | ||||||||
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| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37244 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153290570 | ||||||||
| FaxNumber: | 6153290579 | ||||||||
| Practice Location | |||||||||
| Address1: | 103 PHYSICIANS WAY STE 100 | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370904129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153290570 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2020 | ||||||||
| LastUpdateDate: | 02/28/2020 | ||||||||
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| AuthorizedOfficialLastName: | DOUGLAS | ||||||||
| AuthorizedOfficialFirstName: | PATTIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | PAYER RELATIONS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6155146876 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 02/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.