Provider Demographics
NPI:1780937508
Name:AMERICAN HEALTH IMAGING OF GEORGIA LLC
Entity type:Organization
Organization Name:AMERICAN HEALTH IMAGING OF GEORGIA LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:KATRINA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROELLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-689-1691
Mailing Address - Street 1:PO BOX 745973
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-5973
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 LIBERTY BLVD STE 100
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-2841
Practice Address - Country:US
Practice Address - Phone:770-479-1945
Practice Address - Fax:770-479-1948
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-17
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA01587261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202G474891OtherMEDICARE PTAN