Provider Demographics
NPI:1942251483
Name:RADIOLOGY CENTERS OF GEORGIA, LLC
Entity Type:Organization
Organization Name:RADIOLOGY CENTERS OF GEORGIA, LLC
Other - Org Name:MARIETTA IMAGING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:ELAINE
Authorized Official - Last Name:RAKESTRAW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-607-7339
Mailing Address - Street 1:10 BOWEN CT
Mailing Address - Street 2:P. O. BOX 200155
Mailing Address - City:CARTERSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30120-2494
Mailing Address - Country:US
Mailing Address - Phone:770-607-7339
Mailing Address - Fax:770-607-0789
Practice Address - Street 1:780 CANTON RD NE
Practice Address - Street 2:SUITE 230
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-7241
Practice Address - Country:US
Practice Address - Phone:770-792-1234
Practice Address - Fax:770-607-0789
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2007-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0561982085B0100X, 2085R0202X
GA0575332085B0100X, 2085R0202X
GA0494092085N0700X, 2085R0202X
GA0321672085R0202X
GA0312152085R0202X
GA0493892085R0202X, 2085R0204X
GA0522642085R0202X
GA0578212085R0202X, 2085R0204X
GA0536852085R0202X
GA0575902085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody ImagingGroup - Single Specialty
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiologyGroup - Single Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA47BBBGFMedicare ID - Type Unspecified