Healthcare Provider Details

I. General information

NPI: 1881644110
Provider Name (Legal Business Name): DIAGNOSTIC SYSTEMS OF GEORGIA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 03/31/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 RIVERBEND DR
ROME GA
30161
US

IV. Provider business mailing address

1069 BAXTER ST STE C
ATHENS GA
30606
US

V. Phone/Fax

Practice location:
  • Phone: 706-378-0611
  • Fax: 706-378-0143
Mailing address:
  • Phone: 706-354-1036
  • Fax: 706-354-0529

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License NumberNA
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code261QR0206X
TaxonomyMammography Clinic/Center
License NumberN/A
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code261QM1200X
TaxonomyMagnetic Resonance Imaging (MRI) Clinic/Center
License NumberN/A
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code261QR0206X
TaxonomyMammography Clinic/Center
License Number
License Number StateGA
# 5
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number StateGA
# 6
Primary TaxonomyY
Taxonomy Code261QM1200X
TaxonomyMagnetic Resonance Imaging (MRI) Clinic/Center
License Number
License Number StateGA

VIII. Authorized Official

Name: MR. RICHARD L GRAY
Title or Position: OWNER/CEO
Credential:
Phone: 706-354-1036