Healthcare Provider Details

I. General information

NPI: 1013170109
Provider Name (Legal Business Name): IMAGING CENTER AT BAXTER VILLAGE, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2008
Last Update Date: 07/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

509 6TH BAXTER CROSSING
FORT MILL SC
29708
US

IV. Provider business mailing address

222 S HERLONG AVE
ROCK HILL SC
29732-1158
US

V. Phone/Fax

Practice location:
  • Phone: 803-329-6829
  • Fax:
Mailing address:
  • Phone: 803-329-6829
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM1200X
TaxonomyMagnetic Resonance Imaging (MRI) Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. MICHAEL KYLE BURTNETT
Title or Position: SVP OF OUTPATIENT SERVICES, TENET
Credential:
Phone: 469-893-2153