=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881644110
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DIAGNOSTIC SYSTEMS OF GEORGIA, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/10/2006
-----------------------------------------------------
Last Update Date | 03/31/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16 RIVERBEND DR
-----------------------------------------------------
City | ROME
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30161
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-378-0611
-----------------------------------------------------
Fax | 706-378-0143
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1069 BAXTER ST STE C
-----------------------------------------------------
City | ATHENS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30606
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-354-1036
-----------------------------------------------------
Fax | 706-354-0529
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/CEO
-----------------------------------------------------
Name | MR. RICHARD L GRAY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 706-354-1036
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0200X
-----------------------------------------------------
Taxonomy Name | Radiology Clinic/Center
-----------------------------------------------------
License Number | NA
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QR0206X
-----------------------------------------------------
Taxonomy Name | Mammography Clinic/Center
-----------------------------------------------------
License Number | N/A
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QM1200X
-----------------------------------------------------
Taxonomy Name | Magnetic Resonance Imaging (MRI) Clinic/Center
-----------------------------------------------------
License Number | N/A
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 261QR0206X
-----------------------------------------------------
Taxonomy Name | Mammography Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 261QR0200X
-----------------------------------------------------
Taxonomy Name | Radiology Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 261QM1200X
-----------------------------------------------------
Taxonomy Name | Magnetic Resonance Imaging (MRI) Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------