=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689983777
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEACHTREE MRI LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/06/2010
-----------------------------------------------------
Last Update Date | 10/06/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1380 CARLYSLE PARK DR
-----------------------------------------------------
City | LAWRENCEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30044-2249
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-964-3569
-----------------------------------------------------
Fax | 866-487-7900
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1380 CARLYSLE PARK DR
-----------------------------------------------------
City | LAWRENCEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30044-2249
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-964-3569
-----------------------------------------------------
Fax | 866-487-7900
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICER
-----------------------------------------------------
Name | SYED IMRAN NIAZI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 404-964-3569
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1200X
-----------------------------------------------------
Taxonomy Name | Magnetic Resonance Imaging (MRI) Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------