Provider Demographics
NPI:1295780518
Name:MED CROSS IMAGING LLC
Entity type:Organization
Organization Name:MED CROSS IMAGING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:
Authorized Official - Last Name:ROTUNDO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-374-4305
Mailing Address - Street 1:842 PROFESSIONAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:EASTMAN
Mailing Address - State:GA
Mailing Address - Zip Code:31023-6734
Mailing Address - Country:US
Mailing Address - Phone:478-374-4305
Mailing Address - Fax:478-374-1366
Practice Address - Street 1:842 PROFESSIONAL CENTER DR
Practice Address - Street 2:
Practice Address - City:EASTMAN
Practice Address - State:GA
Practice Address - Zip Code:31023-6734
Practice Address - Country:US
Practice Address - Phone:478-374-4305
Practice Address - Fax:478-374-1366
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-24
Last Update Date:2014-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA049913174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00909466BMedicaid
GA00184214AMedicaid
GAGRP 1184OtherMEDICARE GROUP #
GA065362393BMedicare ID - Type Unspecified
GAGRP 1184OtherMEDICARE GROUP #
GA30BDJXRMedicare ID - Type Unspecified
GA00909466BMedicaid