Provider Demographics
NPI:1932155355
Name:IMAGING ASSOCIATES OF CANTON
Entity Type:Organization
Organization Name:IMAGING ASSOCIATES OF CANTON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:PETERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-479-1945
Mailing Address - Street 1:200 OAKSIDE LN
Mailing Address - Street 2:SUITE A
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-6415
Mailing Address - Country:US
Mailing Address - Phone:770-479-1945
Mailing Address - Fax:770-479-1948
Practice Address - Street 1:200 OAKSIDE LN
Practice Address - Street 2:SUITE A
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-6415
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:2006-05-26
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA10051310OtherAMERIGROUP
GA129908OtherPEACHSTATE
GA000964268LMedicaid
GA319443OtherWELLCARE
GA000964268LMedicaid