Provider Demographics
NPI:1659353936
Name:VIDALIA RADIOLOGY ASSOCIATES
Entity Type:Organization
Organization Name:VIDALIA RADIOLOGY ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TOSAPORN
Authorized Official - Middle Name:
Authorized Official - Last Name:KRASAEATH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:800-382-4023
Mailing Address - Street 1:PO BOX 2049
Mailing Address - Street 2:
Mailing Address - City:MOULTRIE
Mailing Address - State:GA
Mailing Address - Zip Code:31776-2049
Mailing Address - Country:US
Mailing Address - Phone:800-382-4023
Mailing Address - Fax:
Practice Address - Street 1:1703 MEADOWS LN
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-8915
Practice Address - Country:US
Practice Address - Phone:800-382-4023
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-14
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
GAGRP3976Medicare PIN