Provider Demographics
NPI:1427008598
Name:MIDDLE GEORGIA RADIOLOGY, PC
Entity Type:Organization
Organization Name:MIDDLE GEORGIA RADIOLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:F
Authorized Official - Last Name:PARKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-275-0580
Mailing Address - Street 1:PO BOX 1013
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31040-1013
Mailing Address - Country:US
Mailing Address - Phone:478-275-0580
Mailing Address - Fax:478-272-0538
Practice Address - Street 1:2406 BELLEVUE RD
Practice Address - Street 2:ERIN OFFICE PARK, BLDG 12
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021-2842
Practice Address - Country:US
Practice Address - Phone:478-275-0580
Practice Address - Fax:478-272-0538
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAH1064982085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAH106498OtherCORPORATE LICENSE NUMBER