1063473197 NPI number — SAVANNAH RADIOLOGISTS, PA

Table of content: (NPI 1063473197)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063473197 NPI number — SAVANNAH RADIOLOGISTS, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SAVANNAH RADIOLOGISTS, PA
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:
1063473197
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/29/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 JOHNSTON STREET
Provider Second Line Business Mailing Address:
SUITE 12
Provider Business Mailing Address City Name:
SAVANNAH
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31405-5531
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-354-7089
Provider Business Mailing Address Fax Number:
912-692-8957

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 JOHNSTON STREET
Provider Second Line Business Practice Location Address:
SUITE 12
Provider Business Practice Location Address City Name:
SAVANNAH
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31405-5531
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-354-7089
Provider Business Practice Location Address Fax Number:
912-692-8957
Provider Enumeration Date:
03/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BROUGHAN
Authorized Official First Name:
JOYCE
Authorized Official Middle Name:
T
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
912-354-7089

Provider Taxonomy Codes

  • Taxonomy code: 2085N0904X , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085B0100X , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0204X , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085N0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: 034456 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: E05688 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 55002191A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 156053200 . This is a "OWCP" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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