NPIMap

Organization Active NPI

Mecklenburg Diagnostic Imaging LLC

Doing business as Novant Health Imaging Southpark

  • Diagnostic Radiology Physician
  • Charlotte, NC
National Provider Identifier
1093773384
Registry record updated Mar 19, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Diagnostic Radiology PhysicianTaxonomy code 2085R0202X
Legal business name
MECKLENBURG DIAGNOSTIC IMAGING LLC
Doing business as
Novant Health Imaging Southpark
Practice address
6324 Fairview Rd
Suite 120 a
Charlotte, NC 28210-3200
Phone
(704) 362-8444
Fax
(704) 362-3557
NPI assigned
May 3, 2006
Last updated
Mar 19, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 19, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Geoffrey K. Gardner
Title
SVP Finance and Revenue Cycle
Phone
(336) 718-2078

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Diagnostic Radiology Physician 2085R0202X NC Primary

Addresses

Primary practice location

6324 Fairview Rd
Suite 120 a
Charlotte, NC 28210-3200

Mailing address

PO Box 603543
Charlotte, NC 28260-3543
Phone (678) 393-5600

Other identifiers 6

IdentifierTypeStateIssuer
P00315955OtherMEDICARE RR
01514OtherNCBCBS NC
6901514MedicaidNC
153718700OtherNCDOL
NPB300MedicaidSC
SL0083MedicaidSC

Other names 1

  • Novant Health Imaging Southpark Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NC

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20031103000393 NC Part B Supplier - Independent Diagnostic Testing Facility (Idtf) 3375455991 Practice locations: Charlotte, NC

Other NPIs with the same Medicare PAC ID 2

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
34D1014535Novant Health Imaging Southpark6324 Fairview Road Suite 120, Charlotte, NC 28210Certificate of waiverJun 21, 2028

National Provider Directory

National Provider Directory
Tax ID family
Mecklenburg Diagnostic Imaging LLC3 organizations share this tax ID, including this one

Other organizations with this tax ID 2

Organizations that report the same tax identification number in the National Provider Directory.

Member of 1

Organizations this organization is a member of, according to the National Provider Directory.

Locations

6324 Fairview Rd
Ste 105
Charlotte, NC 28210

6324 Fairview Rd
Ste 120A
Charlotte, NC 28210
Phone (704) 362-8444

Practitioners & affiliated clinicians

Practitioners 49

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 49

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1146614400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1710806400000",
    "number": "1093773384",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 603543",
            "city": "CHARLOTTE",
            "state": "NC",
            "postal_code": "282603543",
            "telephone_number": "678-393-5600",
            "fax_number": "770-300-9018"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "6324 FAIRVIEW RD",
            "address_2": "SUITE 120 A",
            "city": "CHARLOTTE",
            "state": "NC",
            "postal_code": "282103200",
            "telephone_number": "704-362-8444",
            "fax_number": "704-362-3557"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MECKLENBURG DIAGNOSTIC IMAGING LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-05-03",
        "last_updated": "2024-03-19",
        "certification_date": "2024-03-19",
        "status": "A",
        "authorized_official_last_name": "GARDNER",
        "authorized_official_first_name": "GEOFFREY",
        "authorized_official_middle_name": "K.",
        "authorized_official_title_or_position": "SVP FINANCE AND REVENUE CYCLE",
        "authorized_official_telephone_number": "336-718-2078",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "2085R0202X",
            "taxonomy_group": "",
            "desc": "Radiology, Diagnostic Radiology",
            "state": "NC",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE RR",
            "identifier": "P00315955",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS NC",
            "identifier": "01514",
            "state": "NC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "6901514",
            "state": "NC"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "DOL",
            "identifier": "153718700",
            "state": "NC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "NPB300",
            "state": "SC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "SL0083",
            "state": "SC"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Novant Health Imaging Southpark",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Charlotte, NC

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 19, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.