Provider Demographics
NPI:1447714662
Name:OSSP IMAGING OF AUGUSTA
Entity type:Organization
Organization Name:OSSP IMAGING OF AUGUSTA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING 'SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:RA'KESHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:BROGDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-783-7619
Mailing Address - Street 1:5788 ROSWELL RD
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328-4904
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1306 TROUPE ST
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30904-4799
Practice Address - Country:US
Practice Address - Phone:706-842-4113
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-23
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology