Healthcare Provider Details

I. General information

NPI: 1871592501
Provider Name (Legal Business Name): PHYSICIAN DIAGNOSTIC SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2005
Last Update Date: 04/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2425 WALL ST SE
CONYERS GA
30013-6342
US

IV. Provider business mailing address

2425 WALL ST SE
CONYERS GA
30013-6342
US

V. Phone/Fax

Practice location:
  • Phone: 678-487-1266
  • Fax: 240-371-8541
Mailing address:
  • Phone: 678-487-1266
  • Fax: 240-371-8541

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code293D00000X
TaxonomyPhysiological Laboratory
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: ANGELA MARIE NAUFUL
Title or Position: VICE PRESIDENT, ACCOUNTS RECEIVABLE
Credential:
Phone: 678-487-1266