Provider Demographics
NPI:1588691539
Name:APPALACHIAN DIAGNOSTIC IMAGING, P.C.
Entity type:Organization
Organization Name:APPALACHIAN DIAGNOSTIC IMAGING, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:J
Authorized Official - Last Name:PETROZZO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:276-597-7333
Mailing Address - Street 1:PO BOX 1065
Mailing Address - Street 2:
Mailing Address - City:GRUNDY
Mailing Address - State:VA
Mailing Address - Zip Code:24614-1065
Mailing Address - Country:US
Mailing Address - Phone:276-597-7333
Mailing Address - Fax:276-597-7303
Practice Address - Street 1:RT 5 BOX 20, STATE ROUTE 83
Practice Address - Street 2:
Practice Address - City:GRUNDY
Practice Address - State:VA
Practice Address - Zip Code:24614
Practice Address - Country:US
Practice Address - Phone:276-935-1136
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-26
Last Update Date:2007-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012371742085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0101029231Medicaid
VA0101029231Medicaid