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General NPI Number Information
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NPI Number | 1154371805
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Entity Type | Organization
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Legal Business Name | MARIETTA DIAGNOSTIC CENTER, LLC
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Dates
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Enumeration Date | 05/12/2006
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Last Update Date | 04/25/2013
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Provider Practice Location Address
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Address Line | 780 CANTON ROAD NE SUITE 230
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City | MARIETTA
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State | GA
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Zip | 30060-8928
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Country | US
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Telephone | 770-792-1234
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Fax | 770-424-1194
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Provider Business Mailing Address
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Address Line | 780 CANTON ROAD NE SUITE 230
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City | MARIETTA
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State | GA
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Zip | 30060-8928
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Country | US
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Telephone | 770-792-1234
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Fax | 770-424-1194
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Authorized Official
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Title or Position | CEO
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Name | MR. MIKE EVERTSEB
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Credential |
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Telephone | 770-792-1234
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0200X
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Taxonomy Name | Radiology Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 2085B0100X
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Taxonomy Name | Body Imaging Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 2085U0001X
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Taxonomy Name | Diagnostic Ultrasound Physician
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 2085N0904X
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Taxonomy Name | Nuclear Radiology Physician
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number |
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License Number State |
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