Provider Demographics
NPI:1972555662
Name:CHILDREN'S DIAGNOSTIC IMAGING OF ATLANTA
Entity type:Organization
Organization Name:CHILDREN'S DIAGNOSTIC IMAGING OF ATLANTA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:BROYLES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-779-2168
Mailing Address - Street 1:PO BOX 2936
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30156-9116
Mailing Address - Country:US
Mailing Address - Phone:770-779-0010
Mailing Address - Fax:
Practice Address - Street 1:1001 JOHNSON FERRY RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1605
Practice Address - Country:US
Practice Address - Phone:404-785-2162
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric RadiologyGroup - Single Specialty