=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750689550
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DIAGNOSTICS IMAGING SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/03/2011
-----------------------------------------------------
Last Update Date | 05/23/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 34 UPPER RIVERDALE RD STE# 102
-----------------------------------------------------
City | RIVERDALE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30274
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-991-6001
-----------------------------------------------------
Fax | 770-991-6002
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 405052
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30384-5002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-802-1464
-----------------------------------------------------
Fax | 678-802-0271
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING MANAGER
-----------------------------------------------------
Name | MS. SYRITA THOMPSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 678-802-1464
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0200X
-----------------------------------------------------
Taxonomy Name | Radiology Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------