MEDICARE: DR. GERALD DOMESCIK M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0202X	Diagnostic Radiology Physician	012247	GA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	202G708830	OTHER	GA	RAILROAD MEDICARE
3	300122041	OTHER	GA	RAILROAD MEDICARE
4	300122052	OTHER	GA	RAILROAD MEDICARE
6	P00098059	OTHER	GA	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1457335101
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GERALD DOMESCIK M.D.

Provider Business Mailing Address
First Line	:	3480 PRESTON RIDGE RD STE 600
Second Line	:	CREDENTIALING DEPARTMENT
City	:	ALPHARETTA
State	:	GA
Zip	:	30005-5462
Country	:	US
Telephone Number	:	770-300-0101
Fax Number	:	770-300-0429

Provider Business Practice Location Address
First Line	:	3193 HOWELL MILL RD NW
Second Line	:	SUITE 110
City	:	ATLANTA
State	:	GA
Zip	:	30327-2119
Country	:	US
Telephone Number	:	404-355-7591
Fax Number	:	404-355-9175

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/05/2005
Last Update Date	:	10/02/2009

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Directions to “ DR. GERALD DOMESCIK M.D.” Practice Location

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