Provider Demographics
NPI:1962483701
Name:NORTHWEST DIAGNOSTIC IMAGING, INC
Entity Type:Organization
Organization Name:NORTHWEST DIAGNOSTIC IMAGING, INC
Other - Org Name:DULUTH DIAGNOSTIC IMAGING, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:SCHAEFER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-300-0101
Mailing Address - Street 1:PO BOX 932391
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31193-2391
Mailing Address - Country:US
Mailing Address - Phone:678-393-5600
Mailing Address - Fax:770-300-9018
Practice Address - Street 1:10670A MEDLOCK BRIDGE RD
Practice Address - Street 2:
Practice Address - City:JOHNS CREEK
Practice Address - State:GA
Practice Address - Zip Code:30097-8404
Practice Address - Country:US
Practice Address - Phone:770-623-1776
Practice Address - Fax:770-623-3533
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-09
Last Update Date:2008-05-20
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
GA226870811OtherUS DEPARTMENT OF LABOR
GACH7800OtherRAILROAD MEDICARE
GACA0798OtherRAILROAD MEDICARE
GADA0357OtherRAILROAD MEDICARE
GACA0798OtherRAILROAD MEDICARE
GA=========011OtherTRICARE
GADA0357OtherRAILROAD MEDICARE
GA=========012OtherBLUE CROSS GEORGIA