=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417964156
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PIEDMONT AREA RADIOLOGY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/02/2006
-----------------------------------------------------
Last Update Date | 07/19/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 713A S FAYETTEVILLE ST
-----------------------------------------------------
City | ASHEBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27203-6405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-629-2240
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 13005
-----------------------------------------------------
City | GREENSBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27415-3005
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | KEVIN BOGGS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 336-274-4285
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------