Provider Demographics
NPI:1801510680
Name:WIDMER, ALEX WILLIAM (RT R VI)
Entity type:Individual
Prefix:
First Name:ALEX
Middle Name:WILLIAM
Last Name:WIDMER
Suffix:
Gender:M
Credentials:RT R VI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 DUBLIN WAY NW
Mailing Address - Street 2:
Mailing Address - City:ADAIRSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30103-3505
Mailing Address - Country:US
Mailing Address - Phone:701-306-4725
Mailing Address - Fax:
Practice Address - Street 1:901 N BROAD ST NE
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30161-5201
Practice Address - Country:US
Practice Address - Phone:706-291-2661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-27
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND5815332471V0106X
GA23RRAGA0213243U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes243U00000XTechnologists, Technicians & Other Technical Service ProvidersRadiology Practitioner Assistant
No2471V0106XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistVascular-Interventional Technology