Provider Demographics
NPI:1275587735
Name:PRESTON RIDGE RADIATION PARTNERS, LP
Entity Type:Organization
Organization Name:PRESTON RIDGE RADIATION PARTNERS, LP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DALE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:MCCORD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-270-5085
Mailing Address - Street 1:1475 MONTREAL RD
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-6922
Mailing Address - Country:US
Mailing Address - Phone:770-270-5085
Mailing Address - Fax:770-270-5803
Practice Address - Street 1:3400 OLD MILTON PKWY
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30005-3710
Practice Address - Country:US
Practice Address - Phone:770-270-5085
Practice Address - Fax:770-270-5803
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA316Medicare ID - Type UnspecifiedGROUP