MEDICARE: FLEXOGENIX GEORGIA PC

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

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	202G707094	OTHER	GA	GEORGIA MEDICARE PTAN
2	7628690001	OTHER	GA	MEDICARE NSC

General Provider Information

NPI Number	:	1518406743
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FLEXOGENIX GEORGIA PC

Provider Business Mailing Address
First Line	:	1000 S HOPE ST STE 101
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90015-4057
Country	:	US
Telephone Number	:	213-455-7803
Fax Number	:	213-261-3816

Provider Business Practice Location Address
First Line	:	4600 ROSWELL RD UNIT E210
Second Line	:
City	:	SANDY SPRINGS
State	:	GA
Zip	:	30342-3197
Country	:	US
Telephone Number	:	213-455-7803
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING COORDINATOR
Name	:	MARTHA FUENTES
Credential	:
Telephone Number	:	213-455-7803

Provider Enumeration Date	:	02/21/2017
Last Update Date	:	10/30/2017

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