=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700199940
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GRIFFIN IMAGING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/16/2010
-----------------------------------------------------
Last Update Date | 06/30/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 220 ROCK STREET
-----------------------------------------------------
City | GRIFFIN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30224
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-229-4660
-----------------------------------------------------
Fax | 770-229-4632
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 931477
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31193-1477
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-229-4660
-----------------------------------------------------
Fax | 770-229-4632
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF BILLING
-----------------------------------------------------
Name | MRS. TRACI L BROWN
-----------------------------------------------------
Credential | MBA
-----------------------------------------------------
Telephone | 706-256-3450
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QR0200X
-----------------------------------------------------
Taxonomy Name | Radiology Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------