1679563035 NPI number — RADIOLOGY ASSOCIATES OF MACON PC

Table of content: (NPI 1679563035)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679563035 NPI number — RADIOLOGY ASSOCIATES OF MACON PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RADIOLOGY ASSOCIATES OF MACON PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1679563035
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/06/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
770 PINE ST STE 290
Provider Second Line Business Mailing Address:
ATTN: RADIOLOGY DEPARTMENT
Provider Business Mailing Address City Name:
MACON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31201-7516
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
478-743-1458
Provider Business Mailing Address Fax Number:
478-755-1332

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
770 PINE ST STE 290
Provider Second Line Business Practice Location Address:
ATTN: RADIOLOGY DEPARTMENT
Provider Business Practice Location Address City Name:
MACON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31201-7516
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
478-743-1458
Provider Business Practice Location Address Fax Number:
478-755-1332
Provider Enumeration Date:
10/26/2005

Additional Information

Authorized Official

Authorized Official Last Name:
GROSSNICKLE
Authorized Official First Name:
MARK
Authorized Official Middle Name:
E
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
478-743-1458

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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