Provider Demographics
NPI:1598157646
Name:MODERN TELERADIOLOGY, LLC
Entity Type:Organization
Organization Name:MODERN TELERADIOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RADIOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:SUNIL
Authorized Official - Middle Name:
Authorized Official - Last Name:KINI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-779-2168
Mailing Address - Street 1:3959 WHITE HORSE LN SE
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080-6408
Mailing Address - Country:US
Mailing Address - Phone:843-259-1938
Mailing Address - Fax:
Practice Address - Street 1:3959 WHITE HORSE LN SE
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-6408
Practice Address - Country:US
Practice Address - Phone:843-259-1938
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-26
Last Update Date:2019-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA058050261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA449977167MMedicaid