MEDICARE: NORTHWEST DIAGNOSTIC IMAGING, INC

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		GA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	CA0798	OTHER	GA	RAILROAD MEDICARE
3	CH7801	OTHER	GA	RAILROAD MEDICARE
4	DA0357	OTHER	GA	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	22687081	OTHER	GA	US DEPARTMENT OF LABOR

General Provider Information

NPI Number	:	1922089713
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHWEST DIAGNOSTIC IMAGING, INC

Provider Business Mailing Address
First Line	:	PO BOX 932391
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	31193-2391
Country	:	US
Telephone Number	:	678-393-5600
Fax Number	:	770-300-9018

Provider Business Practice Location Address
First Line	:	1111 GLYNCO PKWY
Second Line	:
City	:	BRUNSWICK
State	:	GA
Zip	:	31525-7921
Country	:	US
Telephone Number	:	912-261-8890
Fax Number	:	912-261-0342

Authorized Official
Title or Position	:	COO
Name	:	MR. DANIEL J SCHAEFER
Credential	:
Telephone Number	:	770-300-0101

Provider Enumeration Date	:	11/08/2005
Last Update Date	:	05/20/2008

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Directions to “NORTHWEST DIAGNOSTIC IMAGING, INC ” Practice Location

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