Basic Information
| Provider Information | |||||||||
| NPI: | 1831132711 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PALACIOS | ||||||||
| FirstName: | GUILLERMO | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1499 WALTON WAY, SUITE 1400 | ||||||||
| Address2: | ATTN: DONNA RAIFORD | ||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309012660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7068288401 | ||||||||
| FaxNumber: | 7067227235 | ||||||||
| Practice Location | |||||||||
| Address1: | 3501 JOHNSON ST | ||||||||
| Address2: | |||||||||
| City: | HOLLYWOOD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330215421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9549872000 | ||||||||
| FaxNumber: | 9544376628 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2006 | ||||||||
| LastUpdateDate: | 09/27/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | ME99650 | FL | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0205X | 067073 | GA | Y | Allopathic & Osteopathic Physicians | Radiology | Radiological Physics |
ID Information
| ID | Type | State | Issuer | Description | 067073 | 01 | GA | MEDICAL LICENSE | OTHER |