Provider Demographics
NPI:1891848784
Name:DEKALB RADIOLOGIST GROUP, LLC
Entity Type:Organization
Organization Name:DEKALB RADIOLOGIST GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:M
Authorized Official - Last Name:COCKRAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:256-997-2189
Mailing Address - Street 1:PO BOX 680949
Mailing Address - Street 2:
Mailing Address - City:FORT PAYNE
Mailing Address - State:AL
Mailing Address - Zip Code:35968-1610
Mailing Address - Country:US
Mailing Address - Phone:256-997-2189
Mailing Address - Fax:256-638-7445
Practice Address - Street 1:200 MEDICAL CENTER DRIVE
Practice Address - Street 2:
Practice Address - City:FORT PAYNE
Practice Address - State:AL
Practice Address - Zip Code:35968
Practice Address - Country:US
Practice Address - Phone:256-997-2189
Practice Address - Fax:256-638-7445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
L158Medicare ID - Type UnspecifiedGROUP MEDICARE #