Provider Demographics
NPI:1619962503
Name:P E T IMAGING OF FAYETTE LLC
Entity Type:Organization
Organization Name:P E T IMAGING OF FAYETTE LLC
Other - Org Name:TRIDENT PET OF FAYETTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:GUY
Authorized Official - Middle Name:A
Authorized Official - Last Name:MESSER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-692-2371
Mailing Address - Street 1:1275 HIGHWAY 54 W
Mailing Address - Street 2:STE 103
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-4549
Mailing Address - Country:US
Mailing Address - Phone:770-692-2371
Mailing Address - Fax:770-692-2373
Practice Address - Street 1:1275 HIGHWAY 54 W
Practice Address - Street 2:STE 102
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-4549
Practice Address - Country:US
Practice Address - Phone:770-719-3754
Practice Address - Fax:770-719-3804
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRIDENT MOLECULAR IMAGING, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-09-16
Last Update Date:2012-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA47BBBJJMedicare ID - Type Unspecified