Basic Information
| Provider Information | |||||||||
| NPI: | 1740232677 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH GWINNETT RADIOLOGY PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 116075 | ||||||||
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| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30368 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8557091801 | ||||||||
| FaxNumber: | 6103732308 | ||||||||
| Practice Location | |||||||||
| Address1: | 1700 MEDICAL WAY | ||||||||
| Address2: | |||||||||
| City: | SNELLVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30078 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709790200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 10/10/2017 | ||||||||
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| AuthorizedOfficialLastName: | HAYES | ||||||||
| AuthorizedOfficialFirstName: | CHARLOTTE | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | RADIOLOGIST | ||||||||
| AuthorizedOfficialTelephone: | 7709790200 | ||||||||
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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.