Provider Demographics
NPI:1144271107
Name:MEDICAL DIAGNOSTICS OF STATESBORO LLC
Entity type:Organization
Organization Name:MEDICAL DIAGNOSTICS OF STATESBORO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:LANCE
Authorized Official - Middle Name:GABRIEL
Authorized Official - Last Name:PRITCHETT
Authorized Official - Suffix:
Authorized Official - Credentials:BS,RDCS,RDMS,RVT
Authorized Official - Phone:912-681-2848
Mailing Address - Street 1:1601 FAIR RD
Mailing Address - Street 2:SUITE 1100
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-1698
Mailing Address - Country:US
Mailing Address - Phone:912-681-2848
Mailing Address - Fax:912-681-2850
Practice Address - Street 1:1601 FAIR RD
Practice Address - Street 2:SUITE 1100
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-1698
Practice Address - Country:US
Practice Address - Phone:912-681-2848
Practice Address - Fax:912-681-2850
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-15
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA47BBBPHMedicare ID - Type Unspecified