Provider Demographics
NPI:1609848597
Name:MT PLEASANT RADIOLOGY ASSOCIATES LLC
Entity Type:Organization
Organization Name:MT PLEASANT RADIOLOGY ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:YOUNG
Authorized Official - Middle Name:S
Authorized Official - Last Name:SONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:800-879-6274
Mailing Address - Street 1:PO BOX 1247
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30015-1247
Mailing Address - Country:US
Mailing Address - Phone:800-879-6274
Mailing Address - Fax:770-784-7283
Practice Address - Street 1:1118 BROWN ST SW
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30014-2326
Practice Address - Country:US
Practice Address - Phone:800-879-6274
Practice Address - Fax:770-784-7283
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP3949Medicaid
SC7985Medicare ID - Type Unspecified