Healthcare Provider Details

I. General information

NPI: 1326650136
Provider Name (Legal Business Name): TBI DIAGNOSTIC CENTERS OF GEORGIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2020
Last Update Date: 07/05/2023
Certification Date: 07/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4294 MEMORIAL DR STE D
DECATUR GA
30032-1226
US

IV. Provider business mailing address

100 QUIVAS CT SW
ATLANTA GA
30331-7524
US

V. Phone/Fax

Practice location:
  • Phone: 678-203-8802
  • Fax:
Mailing address:
  • Phone:
  • Fax:

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: GAIRY JOHNSON
Title or Position: MANAGING PARTNER
Credential:
Phone: 678-203-8802