Basic Information
| Provider Information | |||||||||
| NPI: | 1265484182 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HENRY COUNTY RADIOLOGY ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 100032 | ||||||||
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| City: | KENNESAW | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301569232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707792176 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1133 EAGLES LANDING PKWY | ||||||||
| Address2: | |||||||||
| City: | STOCKBRIDGE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302815085 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7703892200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MANI | ||||||||
| AuthorizedOfficialFirstName: | BALU | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | AUTHORIZED REPRESENTATIVE | ||||||||
| AuthorizedOfficialTelephone: | 7703892200 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.