Provider Demographics
NPI:1548471030
Name:RADIOLOGY ASSOC OF SOUTH GA, P.C.
Entity type:Organization
Organization Name:RADIOLOGY ASSOC OF SOUTH GA, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNT MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:VICKIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MERRITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-384-6803
Mailing Address - Street 1:110 BOWENS MILL RD
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:GA
Mailing Address - Zip Code:31533-2250
Mailing Address - Country:US
Mailing Address - Phone:912-384-6803
Mailing Address - Fax:912-383-6365
Practice Address - Street 1:1101 OCILLA RD
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:GA
Practice Address - Zip Code:31533-2207
Practice Address - Country:US
Practice Address - Phone:912-384-1900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-25
Last Update Date:2015-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA300030604AMedicaid
GAGRP521Medicare PIN