Healthcare Provider Details

I. General information

NPI: 1942251483
Provider Name (Legal Business Name): RADIOLOGY CENTERS OF GEORGIA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 10/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

780 CANTON RD NE SUITE 230
MARIETTA GA
30060-7241
US

IV. Provider business mailing address

10 BOWEN CT P. O. BOX 200155
CARTERSVILLE GA
30120-2494
US

V. Phone/Fax

Practice location:
  • Phone: 770-792-1234
  • Fax: 770-607-0789
Mailing address:
  • Phone: 770-607-7339
  • Fax: 770-607-0789

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number056198
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number057533
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number049409
License Number StateGA
# 4
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number032167
License Number StateGA
# 5
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number031215
License Number StateGA
# 6
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number049389
License Number StateGA
# 7
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number049409
License Number StateGA
# 8
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number056198
License Number StateGA
# 9
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number057533
License Number StateGA
# 10
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number052264
License Number StateGA
# 11
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number057821
License Number StateGA
# 12
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number053685
License Number StateGA
# 13
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number057590
License Number StateGA
# 14
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number049389
License Number StateGA
# 15
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number057821
License Number StateGA

VIII. Authorized Official

Name: MS. BRENDA ELAINE RAKESTRAW
Title or Position: PRACTICE MANAGER
Credential:
Phone: 770-607-7339