Provider Demographics
NPI:1548267438
Name:SAVANNAH DIAGNOSTIC ASSOC PC
Entity type:Organization
Organization Name:SAVANNAH DIAGNOSTIC ASSOC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:NORTHUP
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-927-3046
Mailing Address - Street 1:12345 MERCY BLVD
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31419-3436
Mailing Address - Country:US
Mailing Address - Phone:912-927-3048
Mailing Address - Fax:912-925-0597
Practice Address - Street 1:12345 MERCY BLVD
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31419-3436
Practice Address - Country:US
Practice Address - Phone:912-927-3048
Practice Address - Fax:912-925-0597
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-07
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA016651174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000018092AMedicaid
GA52241377OtherBLUE CROSS BLUE SHIELD
GA52241377OtherBLUE CROSS BLUE SHIELD
GA000018092AMedicaid