Provider Demographics
NPI:1881644110
Name:DIAGNOSTIC SYSTEMS OF GEORGIA, LLC
Entity Type:Organization
Organization Name:DIAGNOSTIC SYSTEMS OF GEORGIA, LLC
Other - Org Name:COOSA DIAGNOSTIC CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:L
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-354-1036
Mailing Address - Street 1:1069 BAXTER ST
Mailing Address - Street 2:STE C
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606
Mailing Address - Country:US
Mailing Address - Phone:706-354-1036
Mailing Address - Fax:706-354-0529
Practice Address - Street 1:16 RIVERBEND DR
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30161
Practice Address - Country:US
Practice Address - Phone:706-378-0611
Practice Address - Fax:706-378-0143
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-10
Last Update Date:2010-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAN/A261QM1200X, 261QR0206X
GA261QM1200X, 261QR0200X, 261QR0206X
GANA261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No261QR0206XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mammography