Provider Demographics
NPI:1699700716
Name:JACKSON RADIOLOGY ASSOCIATES PA
Entity type:Organization
Organization Name:JACKSON RADIOLOGY ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUNO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:731-541-6174
Mailing Address - Street 1:1947 MADISON ST
Mailing Address - Street 2:STE A
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-8062
Mailing Address - Country:US
Mailing Address - Phone:316-685-2371
Mailing Address - Fax:931-552-6663
Practice Address - Street 1:620 SKYLINE DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-3901
Practice Address - Country:US
Practice Address - Phone:731-541-6174
Practice Address - Fax:731-425-6274
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody ImagingGroup - Multi-Specialty
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiologyGroup - Multi-Specialty
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear RadiologyGroup - Multi-Specialty
No2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric RadiologyGroup - Multi-Specialty
No2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Multi-Specialty
No2085R0203XAllopathic & Osteopathic PhysiciansRadiologyTherapeutic RadiologyGroup - Multi-Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty
No2085R0205XAllopathic & Osteopathic PhysiciansRadiologyRadiological PhysicsGroup - Multi-Specialty
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic UltrasoundGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3729238Medicaid
CO315752OtherMEDICARE PIN
CG710BOtherNEVADA MEDICARE
CACG753ZOtherCALIFORNIA MDCR
DD9799OtherRAILROAD MEDICARE
HICG710COtherPALMETTO HAWAII
CACG753ZOtherCALIFORNIA MDCR
TN3729238Medicaid