Provider Demographics
NPI:1871592501
Name:PHYSICIAN DIAGNOSTIC SERVICES LLC
Entity type:Organization
Organization Name:PHYSICIAN DIAGNOSTIC SERVICES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT, ACCOUNTS RECEIVABLE
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:NAUFUL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-487-1266
Mailing Address - Street 1:2425 WALL ST SE
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30013-6342
Mailing Address - Country:US
Mailing Address - Phone:678-487-1266
Mailing Address - Fax:240-371-8541
Practice Address - Street 1:2425 WALL ST SE
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30013-6342
Practice Address - Country:US
Practice Address - Phone:678-487-1266
Practice Address - Fax:240-371-8541
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-15
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes293D00000XLaboratoriesPhysiological Laboratory
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN019144200Medicaid
FL5216680001Medicare NSC
FL470001486Medicare PIN
GA47BBBDGMedicare ID - Type UnspecifiedIDTF
FLE6576Medicare ID - Type UnspecifiedIDTF
GA470000859Medicare PIN
GAX52212Medicare UPIN