Provider Demographics
NPI:1255376174
Name:GRIFFIN REGIONAL RADIATION THERAPY CENTER, INC.
Entity type:Organization
Organization Name:GRIFFIN REGIONAL RADIATION THERAPY CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:NELDA
Authorized Official - Middle Name:H
Authorized Official - Last Name:CHAMPAGNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-907-0554
Mailing Address - Street 1:725 S 8TH ST
Mailing Address - Street 2:
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30224-4818
Mailing Address - Country:US
Mailing Address - Phone:770-228-3737
Mailing Address - Fax:770-228-9334
Practice Address - Street 1:725 S 8TH ST
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30224-4818
Practice Address - Country:US
Practice Address - Phone:770-228-3737
Practice Address - Fax:770-228-9334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP210Medicare ID - Type Unspecified