Provider Demographics
NPI:1154371805
Name:MARIETTA DIAGNOSTIC CENTER, LLC
Entity type:Organization
Organization Name:MARIETTA DIAGNOSTIC CENTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:EVERTSEB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-792-1234
Mailing Address - Street 1:780 CANTON ROAD NE
Mailing Address - Street 2:SUITE 230
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-8928
Mailing Address - Country:US
Mailing Address - Phone:770-792-1234
Mailing Address - Fax:770-424-1194
Practice Address - Street 1:780 CANTON ROAD NE
Practice Address - Street 2:SUITE 230
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-8928
Practice Address - Country:US
Practice Address - Phone:770-792-1234
Practice Address - Fax:770-424-1194
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARIETTA DIAGNOSTIC CENTER, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-12
Last Update Date:2013-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody ImagingGroup - Single Specialty
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear RadiologyGroup - Single Specialty
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic UltrasoundGroup - Single Specialty
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA764269020AMedicaid
GA47BBBFMedicare UPIN
GA764269020AMedicaid