Provider Demographics
NPI:1518406743
Name:FLEXOGENIX GEORGIA PC
Entity Type:Organization
Organization Name:FLEXOGENIX GEORGIA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:FUENTES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:213-455-7803
Mailing Address - Street 1:1000 S HOPE ST STE 101
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90015-4057
Mailing Address - Country:US
Mailing Address - Phone:213-455-7803
Mailing Address - Fax:213-261-3816
Practice Address - Street 1:4600 ROSWELL RD UNIT E210
Practice Address - Street 2:
Practice Address - City:SANDY SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30342-3197
Practice Address - Country:US
Practice Address - Phone:213-455-7803
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-21
Last Update Date:2017-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202G707094OtherGEORGIA MEDICARE PTAN
GA7628690001OtherMEDICARE NSC