=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093017006
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IMAGING CENTERS OF GEORGIA, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/23/2010
-----------------------------------------------------
Last Update Date | 07/09/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 108 OLYMPIA DR SUITE 101
-----------------------------------------------------
City | WARNER ROBINS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31093
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-302-5270
-----------------------------------------------------
Fax | 478-302-5280
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 108 OLYMPIA DR SUITE 101
-----------------------------------------------------
City | WARNER ROBINS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31093-3682
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-302-5270
-----------------------------------------------------
Fax | 478-302-5280
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/CEO
-----------------------------------------------------
Name | MR. NORMAN W. KING
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 478-302-5270
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QR0200X
-----------------------------------------------------
Taxonomy Name | Radiology Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QR0208X
-----------------------------------------------------
Taxonomy Name | Mobile Radiology Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------