Provider Demographics
NPI:1255444519
Name:CEDARTOWN RADIOLOGY GROUP
Entity type:Organization
Organization Name:CEDARTOWN RADIOLOGY GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GREG
Authorized Official - Middle Name:L
Authorized Official - Last Name:DOVER
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:770-237-1558
Mailing Address - Street 1:1605 LAKES PKWY
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-5858
Mailing Address - Country:US
Mailing Address - Phone:770-237-1148
Mailing Address - Fax:770-237-6148
Practice Address - Street 1:424 NORTH MAIN ST
Practice Address - Street 2:
Practice Address - City:CEDARTOWN
Practice Address - State:GA
Practice Address - Zip Code:30125
Practice Address - Country:US
Practice Address - Phone:770-748-2500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-17
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA30BDHLHMedicare PIN