Provider Demographics
NPI:1326139627
Name:PENN TECK DIAGNOSTICS INC
Entity Type:Organization
Organization Name:PENN TECK DIAGNOSTICS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:WEEMS
Authorized Official - Middle Name:R
Authorized Official - Last Name:PENNINGTON
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:706-722-6612
Mailing Address - Street 1:820 ST. SEBASTIAN WAY,
Mailing Address - Street 2:SUITE 2B
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30901
Mailing Address - Country:US
Mailing Address - Phone:706-722-6612
Mailing Address - Fax:706-722-5057
Practice Address - Street 1:820 ST. SEBASTIAN WAY,
Practice Address - Street 2:SUITE 2B
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30901
Practice Address - Country:US
Practice Address - Phone:706-722-6612
Practice Address - Fax:706-722-5057
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2011-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA014977207UN0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear CardiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00094179CMedicaid
SCGPA518Medicaid
SC4963Medicare PIN
SCGPA518Medicaid
GAGRP1677Medicare PIN