Healthcare Provider Details

I. General information

NPI: 1821341272
Provider Name (Legal Business Name): COMMERCE RADIOLOGY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2012
Last Update Date: 10/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

70 MEDICAL CENTER DR
COMMERCE GA
30529-1078
US

IV. Provider business mailing address

108 VENTURE CT
GREENWOOD SC
29649-8558
US

V. Phone/Fax

Practice location:
  • Phone: 706-335-1420
  • Fax: 864-223-1396
Mailing address:
  • Phone: 864-223-3070
  • Fax: 864-223-1396

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number020769
License Number StateGA

VIII. Authorized Official

Name: THAD DEWARD LONG
Title or Position: OWNER
Credential: MD
Phone: 678-469-0007