MEDICARE: ADVANCED DIAGNOSTIC IMAGING, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0202X	Diagnostic Radiology Physician

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	CN8540	OTHER	GA	MEDICARE RAILROAD

General Provider Information

NPI Number	:	1346313558
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ADVANCED DIAGNOSTIC IMAGING, LLC

Provider Business Mailing Address
First Line	:	PO BOX 2729
Second Line	:
City	:	ORANGEBURG
State	:	SC
Zip	:	29116-2729
Country	:	US
Telephone Number	:	803-534-0053
Fax Number	:	803-536-1198

Provider Business Practice Location Address
First Line	:	1728 VILLAGE PARK DR
Second Line	:
City	:	ORANGEBURG
State	:	SC
Zip	:	29118-2426
Country	:	US
Telephone Number	:	803-534-0053
Fax Number	:	803-536-1198

Authorized Official
Title or Position	:	CEO
Name	:	CYNTHIA G WAYSTACK
Credential	:
Telephone Number	:	803-534-0053

Provider Enumeration Date	:	11/16/2006
Last Update Date	:	11/08/2010

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