=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316066913
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE RADIOLOGY GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/28/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 600 S 3RD ST
-----------------------------------------------------
City | GADSDEN
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35901-5304
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-543-5200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 3026
-----------------------------------------------------
City | KENNESAW
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30156-9118
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-272-7799
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JERRY W MITCHELL
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 256-543-5200
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------