MEDICARE: ADVANCED DIAGNOSTIC IMAGING, PC

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	213E00000X	Podiatrist

General Provider Information

NPI Number	:	1417571498
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ADVANCED DIAGNOSTIC IMAGING, PC

Provider Business Mailing Address
First Line	:	3024 BUSINESS PARK CIR
Second Line	:
City	:	GOODLETTSVILLE
State	:	TN
Zip	:	37072-3132
Country	:	US
Telephone Number	:	615-851-6033
Fax Number	:

Provider Business Practice Location Address
First Line	:	353 NEW SHACKLE ISLAND RD STE 120B
Second Line	:
City	:	HENDERSONVILLE
State	:	TN
Zip	:	37075-2329
Country	:	US
Telephone Number	:	615-826-0941
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING MANAGER
Name	:	SUSAN FENTON
Credential	:
Telephone Number	:	615-851-6033

Provider Enumeration Date	:	06/04/2020
Last Update Date	:	06/04/2020

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