Provider Demographics
NPI:1255312070
Name:NORTHWEST DIAGNOSTIC IMAGING, INC
Entity type:Organization
Organization Name:NORTHWEST DIAGNOSTIC IMAGING, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
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 1:2601 N DECATUR RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-6127
Practice Address - Country:US
Practice Address - Phone:404-329-0656
Practice Address - Fax:404-329-0207
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-09
Last Update Date:2011-08-24
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
GACA0798OtherRAILROAD MEDICARE
GA226870813OtherUS DEPARRTMENT OF LABOR
GACH7800OtherRAILROAD MEDICARE
GADA0357OtherRAILROAD MEDICARE
GA=========033OtherUNITED HEALTHCARE
GA=========010OtherBLUE CROSS GEORGIA
GACH7800OtherRAILROAD MEDICARE
GADA0357OtherRAILROAD MEDICARE