Healthcare Provider Details

I. General information

NPI: 1407802978
Provider Name (Legal Business Name): CARDIOVASCULAR IMAGING OF NORTH GEORGIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

97 HEFNER ST SUITE 102
EAST ELLIJAY GA
30540-8260
US

IV. Provider business mailing address

1100 JOHNSON FERRY RD NE SUITE 1065
ATLANTA GA
30342-1709
US

V. Phone/Fax

Practice location:
  • Phone: 706-636-6500
  • Fax:
Mailing address:
  • Phone: 404-851-5415
  • Fax: 404-303-2393

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number017225
License Number StateGA

VIII. Authorized Official

Name: DR. WILLIAM S KNAPP
Title or Position: COORDINATOR
Credential: MD
Phone: 706-636-6500