1467524330 NPI number — WEST COBB INTERNAL MEDICINE PC

Table of content: (NPI 1467524330)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467524330 NPI number — WEST COBB INTERNAL MEDICINE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WEST COBB INTERNAL MEDICINE PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CHIDAMBARAM RAGHAVAN MD
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1467524330
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5041 DALLAS HIGHWAY
Provider Second Line Business Mailing Address:
BLDG 2 SUITE E WEST COBB INTERNAL MEDICINE PC
Provider Business Mailing Address City Name:
POWDER SPRINGS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30127
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-218-1880
Provider Business Mailing Address Fax Number:
770-218-1088

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5041 DALLAS HWY
Provider Second Line Business Practice Location Address:
BLDG 2 SUITE E WEST COBB INTERNAL MEDICINE PC
Provider Business Practice Location Address City Name:
POWDER SPRINGS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30127
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-218-1880
Provider Business Practice Location Address Fax Number:
770-218-1088
Provider Enumeration Date:
11/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
RAGHAVAN
Authorized Official First Name:
CHIDAMBARAM
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
770-218-1880

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  38709 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00626117A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4562104 . This is a "AETNA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 0400005 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 617437 . This is a "BCBS" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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