Basic Information
| Provider Information | |||||||||
| NPI: | 1487680732 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHERN TENNESSEE RADIOLOGY | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2125 | ||||||||
| Address2: | |||||||||
| City: | DALTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8664579896 | ||||||||
| FaxNumber: | 7062262283 | ||||||||
| Practice Location | |||||||||
| Address1: | 185 HOSPITAL RD | ||||||||
| Address2: | |||||||||
| City: | WINCHESTER | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37398 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8664579896 | ||||||||
| FaxNumber: | 7062262283 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2006 | ||||||||
| LastUpdateDate: | 10/23/2007 | ||||||||
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| AuthorizedOfficialLastName: | ELLIS | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8664579896 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Radiology |
ID Information
| ID | Type | State | Issuer | Description | 3732584 | 05 | TN | MEDICAID | DE2147 | 01 | TN | RAILROAD MEDICARE | OTHER |