Healthcare Provider Details

I. General information

NPI: 1265484182
Provider Name (Legal Business Name): HENRY COUNTY RADIOLOGY ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1133 EAGLES LANDING PKWY
STOCKBRIDGE GA
30281-5085
US

IV. Provider business mailing address

PO BOX 100032
KENNESAW GA
30156-9232
US

V. Phone/Fax

Practice location:
  • Phone: 770-389-2200
  • Fax:
Mailing address:
  • Phone: 770-779-2176
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: BALU S MANI
Title or Position: AUTHORIZED REPRESENTATIVE
Credential: MD
Phone: 770-389-2200