1437149762 NPI number — CENTRAL GEORGIA PET LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437149762 NPI number — CENTRAL GEORGIA PET LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTRAL GEORGIA PET LLC
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:
1437149762
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:
1650 HARDEMAN AVE
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:
31201-1418
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
478-633-4738
Provider Business Mailing Address Fax Number:
478-749-9736

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1650 HARDEMAN AVE
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:
31201-1418
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
478-633-4738
Provider Business Practice Location Address Fax Number:
478-749-9736
Provider Enumeration Date:
10/27/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ZINSMEISTER
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
478-633-4738

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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