Provider Demographics
NPI:1154302990
Name:NORTHWEST DIAGNOSTIC IMAGING, INC
Entity Type:Organization
Organization Name:NORTHWEST DIAGNOSTIC IMAGING, INC
Other - Org Name:OPEN MRI & IMAGING OF DOUGLASVILLE, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:SCHAEFER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-300-0101
Mailing Address - Street 1:PO BOX 932391
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31193-2391
Mailing Address - Country:US
Mailing Address - Phone:678-393-5600
Mailing Address - Fax:770-300-9018
Practice Address - Street 1:6095 PROFESSIONAL PKWY
Practice Address - Street 2:SUITE 101B
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134-5607
Practice Address - Country:US
Practice Address - Phone:770-947-8100
Practice Address - Fax:770-947-3404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-09
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GACA0798OtherRAILROAD MEDICARE
GACH7800OtherRAILROAD MEDICARE
GADA0357OtherRAILROAD MEDICARE
GA226870812OtherUS DEPARTMENT OF LABOR
GA=========011OtherBLUE CROSS GEORGIA
GA=========012OtherTRICARE
GACH7800OtherRAILROAD MEDICARE
GACH7800OtherRAILROAD MEDICARE