Healthcare Provider Details

I. General information

NPI: 1104285659
Provider Name (Legal Business Name): ATHENS NEIGHBORHOOD DIAGNOSTIC CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2016
Last Update Date: 07/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

675 COLLEGE AVE
ATHENS GA
30601
US

IV. Provider business mailing address

P O BOX 147
ATHENS GA
30603-1442
US

V. Phone/Fax

Practice location:
  • Phone: 706-546-5526
  • Fax: 706-546-5867
Mailing address:
  • Phone: 706-850-9041
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number29631
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: MS. ALMENA SMITH
Title or Position: BILLING MANAGER
Credential:
Phone: 706-850-9041