1932240124 NPI number — MUSHARAF MOMIN INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932240124 NPI number — MUSHARAF MOMIN INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MUSHARAF MOMIN INC
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:
MCDONOUGH ADULT & PEDIATRIC MEDICAL CARE
Provider Other Organization Name Type Code:
3
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:
1932240124
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/30/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2437 LAKE ERMA DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAMPTON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30228-6087
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-783-1558
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
130 EAGLE SPRING CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STOCKBRIDGE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30281-7274
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-759-2278
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MOMIN
Authorized Official First Name:
MUSHARAF
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
404-783-1767

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , 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)





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