Provider Demographics
NPI:1447316963
Name:CAROLINA IMAGING CONSULTANTS P A
Entity type:Organization
Organization Name:CAROLINA IMAGING CONSULTANTS P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:DWIGHT
Authorized Official - Last Name:GOLTRA
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:843-819-2665
Mailing Address - Street 1:PO BOX 100523
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29501-0523
Mailing Address - Country:US
Mailing Address - Phone:843-669-5162
Mailing Address - Fax:843-667-4573
Practice Address - Street 1:582 LONG POINT ROAD
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464
Practice Address - Country:US
Practice Address - Phone:843-819-2665
Practice Address - Fax:843-971-8832
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-29
Last Update Date:2008-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4033Medicaid
SC=========OtherTAX ID
SC=========OtherSTANDARD TAX ID
SCGP4033Medicaid
SC=========OtherBCBS OF SC