Healthcare Provider Details

I. General information

NPI: 1255444519
Provider Name (Legal Business Name): CEDARTOWN RADIOLOGY GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2006
Last Update Date: 11/30/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

424 NORTH MAIN ST
CEDARTOWN GA
30125
US

IV. Provider business mailing address

1605 LAKES PKWY
LAWRENCEVILLE GA
30043-5858
US

V. Phone/Fax

Practice location:
  • Phone: 770-748-2500
  • Fax:
Mailing address:
  • Phone: 770-237-1148
  • Fax: 770-237-6148

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: GREG L. DOVER
Title or Position: PRACTICE MANAGER
Credential: CPA
Phone: 770-237-1558