Provider Demographics
NPI:1114908522
Name:CENTRAL GEORGIA MRI LLC
Entity Type:Organization
Organization Name:CENTRAL GEORGIA MRI LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:E
Authorized Official - Last Name:GROSSNICKLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:478-746-1020
Mailing Address - Street 1:770 PINE ST STE L15
Mailing Address - Street 2:ATTN: RADIOLOGY DEPARTMENT
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-7519
Mailing Address - Country:US
Mailing Address - Phone:478-746-1020
Mailing Address - Fax:478-746-0591
Practice Address - Street 1:770 PINE ST STE L15
Practice Address - Street 2:ATTN: RADIOLOGY DEPARTMENT
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-7519
Practice Address - Country:US
Practice Address - Phone:478-746-1020
Practice Address - Fax:478-746-0591
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-11
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty