1952419012 NPI number — SOUTH GEORGIA RADIOLOGY CONSULTANTS, PC

Table of content: (NPI 1952419012)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952419012 NPI number — SOUTH GEORGIA RADIOLOGY CONSULTANTS, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH GEORGIA RADIOLOGY CONSULTANTS, 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:
1952419012
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/22/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 3201
Provider Second Line Business Mailing Address:
1125 TROUPE STREET
Provider Business Mailing Address City Name:
AUGUSTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30914-3201
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-737-4575
Provider Business Mailing Address Fax Number:
706-731-5289

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5843 DEOSTA DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE PARK
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31636-3405
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
229-259-4888
Provider Business Practice Location Address Fax Number:
229-559-8178
Provider Enumeration Date:
08/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MILLNER
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
R.
Authorized Official Title or Position:
MD OWNER
Authorized Official Telephone Number:
706-737-4575

Provider Taxonomy Codes

  • Taxonomy code: 2085B0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085D0003X ; 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: 2085N0904X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085P0229X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0204X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085U0001X ; 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: "Y" .

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

  • Identifier: 1447200399 . This is a "NPI - MICHAEL MILLNER, MD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 157743000 . This is a "ACS DOL" identifier . This identifiers is of the category "OTHER".
  • Identifier: 016879800 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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