NPIMap

Organization Active NPI

Jacksonville Diagnostic Imaging LLC

  • Diagnostic Radiology Physician
  • Jacksonville, NC
National Provider Identifier
1104874387
Registry record updated Mar 19, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Diagnostic Radiology PhysicianTaxonomy code 2085R0202X
Legal business name
JACKSONVILLE DIAGNOSTIC IMAGING LLC
Practice address
3606 Henderson Dr
Jacksonville, NC 28546-5217
Phone
(910) 937-7226
Fax
(910) 937-0064
NPI assigned
May 4, 2006
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 PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 2085R0202X NC Primary

Addresses

Primary practice location

3606 Henderson Dr
Jacksonville, NC 28546-5217

Mailing address

PO Box 933393
Atlanta, GA 31193-0001
Phone (866) 659-1211

Other identifiers 4

IdentifierTypeStateIssuer
89014UNMedicaidNC
014UNOtherNCBCBS NC
101136600OtherNCDOL
P00107621OtherNCMEDICARE RAILROAD

Other names 1

  • Coastal Diagnostic Imaging Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040304000483 NC Part B Supplier - Independent Diagnostic Testing Facility (Idtf) 2466349212 Practice locations: Jacksonville, NC

National Provider Directory

National Provider Directory

Member of 2

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

Practitioners & affiliated clinicians

Practitioners 16

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 16

NPI Registry JSON

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

{
    "created_epoch": "1146700800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1710806400000",
    "number": "1104874387",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 933393",
            "city": "ATLANTA",
            "state": "GA",
            "postal_code": "311930001",
            "telephone_number": "866-659-1211",
            "fax_number": "336-774-1751"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3606 HENDERSON DR",
            "city": "JACKSONVILLE",
            "state": "NC",
            "postal_code": "285465217",
            "telephone_number": "910-937-7226",
            "fax_number": "910-937-0064"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "JACKSONVILLE DIAGNOSTIC IMAGING LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-05-04",
        "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": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Radiology, Diagnostic Radiology",
            "state": "NC",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "89014UN",
            "state": "NC"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS NC",
            "identifier": "014UN",
            "state": "NC"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "DOL",
            "identifier": "101136600",
            "state": "NC"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE RAILROAD",
            "identifier": "P00107621",
            "state": "NC"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Coastal Diagnostic Imaging",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Jacksonville, 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.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.