Provider Demographics
NPI:1114902053
Name:AMERICAN HEALTH IMAGING OF GEORGIA LLC
Entity Type:Organization
Organization Name:AMERICAN HEALTH IMAGING OF GEORGIA LLC
Other - Org Name:AMERICAN HEALTH IMAGING OF WEST COBB LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER OF CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:JANE
Authorized Official - Middle Name:TRAVIS
Authorized Official - Last Name:LUTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-362-5391
Mailing Address - Street 1:PO BOX 933367
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31193-3367
Mailing Address - Country:US
Mailing Address - Phone:404-296-5887
Mailing Address - Fax:404-296-3129
Practice Address - Street 1:2615 E WEST CONNECTOR
Practice Address - Street 2:SUITE 122
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-6848
Practice Address - Country:US
Practice Address - Phone:770-739-9770
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-14
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA47BBBKSMedicare PIN