Contract Details
Ancillary Care Services
Facility name
Coosa Diagnostic Center
Provider ID
P000005529
NPI
1881644110
Tax ID
582408271
Effective Date
4/1/2012
Last Updated
9/30/2013
Direct Contract
No
Status
Active
Contract Discounts
Discount Type
S
State Fee Schedule Multiplier
68.00
Location Details
Address
1069 Baxter Street Suite C
Athens, GA 30606
United States
County
Clarke
Phone
7063163662 (Phone)
Billing Details
Address
5429 LBJ Freeway
Suite 700
Dallas, TX 75240
Specialty Type
Diagnostic Services
Map
Address