Healthcare Provider Details

I. General information

NPI: 1174785240
Provider Name (Legal Business Name): DIGITAL MAMMOGRAPHY SPECIALISTS-EAGLES LANDING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2008
Last Update Date: 10/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 EAGLE SPRING DR SUITE 100
STOCKBRIDGE GA
30281-6486
US

IV. Provider business mailing address

200 ARIZONA AVE NE SUITE 200
ATLANTA GA
30307-2299
US

V. Phone/Fax

Practice location:
  • Phone: 678-904-7209
  • Fax: 770-507-5199
Mailing address:
  • Phone: 678-904-6820
  • Fax: 678-904-6824

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0206X
TaxonomyMammography Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. MANJU R. MORRISSEY
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: M.D.
Phone: 678-904-6820