Basic Information
| Provider Information | |||||||||
| NPI: | 1073575296 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LOGIC RADIOLOGY, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 753 JOHNNIE DODDS BLVD | ||||||||
| Address2: | |||||||||
| City: | MT PLEASANT | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294643054 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8432843400 | ||||||||
| FaxNumber: | 8432843401 | ||||||||
| Practice Location | |||||||||
| Address1: | 1601 WATSON BLVD | ||||||||
| Address2: | |||||||||
| City: | WARNER ROBINS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310933431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4785427765 | ||||||||
| FaxNumber: | 4789234104 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | VELNATI | ||||||||
| AuthorizedOfficialFirstName: | APARNA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4785427765 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 052326 | GA | X | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085P0229X | 056665 | GA | X | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology |
ID Information
| ID | Type | State | Issuer | Description | CJ8165 | 01 | GA | RR MEDICARE | OTHER |