Healthcare Provider Details

I. General information

NPI: 1871407064
Provider Name (Legal Business Name): GEORGIA BREAST RADIOLOGY SPECIALISTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2026
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 GRAND CENTRAL BLVD STE 106
POOLER GA
31322-4148
US

IV. Provider business mailing address

15601 DALLAS PKWY STE 300
ADDISON TX
75001-6012
US

V. Phone/Fax

Practice location:
  • Phone: 866-717-2551
  • Fax:
Mailing address:
  • Phone: 866-717-2551
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: MICHAEL J DELEO III
Title or Position: AUTHORIZED OFFICIAL
Credential: MD
Phone: 610-745-4400