Provider Demographics
NPI:1760669931
Name:SOUTH GEORGIA RADIOLOGY ASSOCIATES, LLC
Entity type:Organization
Organization Name:SOUTH GEORGIA RADIOLOGY ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:CASTLEBERRY
Authorized Official - Suffix:
Authorized Official - Credentials:AO
Authorized Official - Phone:912-764-2455
Mailing Address - Street 1:PO BOX 1067
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30459-1067
Mailing Address - Country:US
Mailing Address - Phone:912-764-2455
Mailing Address - Fax:912-764-7522
Practice Address - Street 1:7505 WATERS AVE STE F10
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-3822
Practice Address - Country:US
Practice Address - Phone:706-975-5993
Practice Address - Fax:912-304-5793
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-29
Last Update Date:2024-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0559372085R0202X, 2085R0204X
2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA=========OtherTAX ID