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General NPI Number Information
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NPI Number | 1730130345
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Entity Type | Organization
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Legal Business Name | PREMIER DIAGNOSTIC IMAGING, LLC
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Dates
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Enumeration Date | 05/16/2006
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Last Update Date | 09/17/2020
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Provider Practice Location Address
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Address Line | 315 N WASHINGTON AVE SUITE 103
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City | COOKEVILLE
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State | TN
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Zip | 38501-2603
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Country | US
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Telephone | 931-528-1800
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Fax | 931-528-2443
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Provider Business Mailing Address
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Address Line | PO BOX 1502
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City | COOKEVILLE
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State | TN
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Zip | 38503-1502
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Country | US
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Telephone | 931-528-1800
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Fax | 931-528-1488
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Authorized Official
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Title or Position | PROVIDER/PRESIDENT
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Name | MR. WILLIAM M HUMPHREY
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Credential | MD
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Telephone | 931-528-2443
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | MD6278
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License Number State | TN
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