MEDICARE: MARIETTA DIAGNOSTIC CENTER, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	261QR0200X	Radiology Clinic/Center
2	2085B0100X	Body Imaging Physician
3	2085U0001X	Diagnostic Ultrasound Physician
4	2085N0904X	Nuclear Radiology Physician
5	2085R0202X	Diagnostic Radiology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1154371805
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARIETTA DIAGNOSTIC CENTER, LLC

Provider Business Mailing Address
First Line	:	780 CANTON ROAD NE
Second Line	:	SUITE 230
City	:	MARIETTA
State	:	GA
Zip	:	30060-8928
Country	:	US
Telephone Number	:	770-792-1234
Fax Number	:	770-424-1194

Provider Business Practice Location Address
First Line	:	780 CANTON ROAD NE
Second Line	:	SUITE 230
City	:	MARIETTA
State	:	GA
Zip	:	30060-8928
Country	:	US
Telephone Number	:	770-792-1234
Fax Number	:	770-424-1194

Authorized Official
Title or Position	:	CEO
Name	:	MR. MIKE EVERTSEB
Credential	:
Telephone Number	:	770-792-1234

Provider Enumeration Date	:	05/12/2006
Last Update Date	:	04/25/2013

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Directions to “MARIETTA DIAGNOSTIC CENTER, LLC ” Practice Location

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