Medical School Information |
|
Medical School Name
|
EAST TENNESSEE STATE UNIVERSITY QUILLEN COLLEGE OF MEDICINE
|
|
Individual professional's medical school
|
|
Graduation Year
|
1998
|
|
Individual professional's medical school graduation year
|
|
Primary Specialty
|
DIAGNOSTIC RADIOLOGY
|
|
Primary medical specialty reported by the individual professional in the selected enrollment
|
|
Secondary Specialty 1
|
INTERVENTIONAL RADIOLOGY
|
|
First secondary medical specialty reported by the individual professional in the selected enrollment
|
|
All Secondary Specialties
|
INTERVENTIONAL RADIOLOGY
|
|
All four secondary specialties reported by the individual professional in the selected enrollment, separated by commas
|
Practice Information |
|
Organization Legal Name
|
SOUTHERN RADIOLOGY ASSOCIATES, PLLC
|
|
Legal name of the Group Practice that the individual professional works with- will be blank if the address is not linked to a Group Practice
|
|
Group Practice PAC ID
|
7214913649
|
|
Unique Group Practice ID assigned by PECOS to the Group Practice that the individual professional works with- will be blank if the address is not linked to a Group Practice
|
|
Number of Group Practice members
|
12
|
|
Total number of individual professionals affiliated with the Group Practice based on Group Practice PAC ID
|
|
Line 1 Street Address
|
1224 TROTWOOD AVE
|
|
Group Practice or individual's line 1 address
|
|
City
|
COLUMBIA
|
|
Group Practice or individual's city
|
|
State
|
TN
|
|
Group Practice or individual's state
|
|
Zip Code
|
384014802
|
|
Group Practice or individual's zip code (9 digits when available)
|
|
Phone Number
|
9313811111
|
|
Phone number is listed only when there is a single phone number available for the practice location address
|
Hospital(s) Affiliation Information |
|
Hospital Affiliation CCN 1
|
440073
|
|
Medicare CCN of hospital where individual professional provides service 1
|
|
Hospital Affiliation LBN 1
|
MAURY REGIONAL HOSPITAL
|
|
Legal business name of hospital where individual professional provides service 1
|
|
Hospital Affiliation CCN 2
|
440137
|
|
Medicare CCN of hospital where individual professional provides service 2
|
|
Hospital Affiliation LBN 2
|
TENNOVA HEALTHCARE-SHELBYVILLE
|
|
Legal business name of hospital where individual professional provides service 2
|
|
Hospital Affiliation CCN 3
|
441309
|
|
Medicare CCN of hospital where individual professional provides service 3
|
|
Hospital Affiliation LBN 3
|
MARSHALL MEDICAL CENTER
|
|
Legal business name of hospital where individual professional provides service 3
|
|
Hospital Affiliation CCN 4
|
110016
|
|
Medicare CCN of hospital where individual professional provides service 4
|
|
Hospital Affiliation LBN 4
|
WEST GEORGIA MEDICAL CENTER, INC
|
|
Legal business name of hospital where individual professional provides service 4
|
|
Hospital Affiliation CCN 5
|
440010
|
|
Medicare CCN of hospital where individual professional provides service 5
|
|
Hospital Affiliation LBN 5
|
WAYNE MEDICAL CENTER
|
|
Legal business name of hospital where individual professional provides service 5
|
|
Professional Accepts Medicare Assignment
|
Y
|
|
|