Healthcare Provider Details

I. General information

NPI: 1437149762
Provider Name (Legal Business Name): CENTRAL GEORGIA PET LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2005
Last Update Date: 11/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 HARDEMAN AVE ATTN: RADIOLOGY DEPARTMENT
MACON GA
31201-1418
US

IV. Provider business mailing address

1650 HARDEMAN AVE ATTN: RADIOLOGY DEPARTMENT
MACON GA
31201-1418
US

V. Phone/Fax

Practice location:
  • Phone: 478-633-4738
  • Fax: 478-749-9736
Mailing address:
  • Phone: 478-633-4738
  • Fax: 478-749-9736

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL ZINSMEISTER
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 478-633-4738