Healthcare Provider Details

I. General information

NPI: 1154371805
Provider Name (Legal Business Name): MARIETTA DIAGNOSTIC CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 04/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

780 CANTON ROAD NE SUITE 230
MARIETTA GA
30060-8928
US

IV. Provider business mailing address

780 CANTON ROAD NE SUITE 230
MARIETTA GA
30060-8928
US

V. Phone/Fax

Practice location:
  • Phone: 770-792-1234
  • Fax: 770-424-1194
Mailing address:
  • Phone: 770-792-1234
  • Fax: 770-424-1194

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. MIKE EVERTSEB
Title or Position: CEO
Credential:
Phone: 770-792-1234