Healthcare Provider Details

I. General information

NPI: 1659557122
Provider Name (Legal Business Name): SAMUEL THOMAS ROLLEY CNMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2008
Last Update Date: 01/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

795 N BELAIR RD
EVANS GA
30809-4258
US

IV. Provider business mailing address

PO BOX 514
EVANS GA
30809-0514
US

V. Phone/Fax

Practice location:
  • Phone: 912-604-3889
  • Fax:
Mailing address:
  • Phone: 912-604-3889
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2471N0900X
TaxonomyNuclear Medicine Technology Radiologic Technologist
License Number022395
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: