1093109795 NPI number — MEDICAL ASSOCIATES OF GEORGIA

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 1093109795 NPI number — MEDICAL ASSOCIATES OF GEORGIA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDICAL ASSOCIATES OF GEORGIA
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:
Provider Other Organization Name Type Code:
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:
1093109795
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/20/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3584 OLD MILTON PKWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALPHARETTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30005-4465
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-691-3388
Provider Business Mailing Address Fax Number:
678-395-7702

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1462 MONTREAL RD
Provider Second Line Business Practice Location Address:
307
Provider Business Practice Location Address City Name:
TUCKER
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30084-6929
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-938-5552
Provider Business Practice Location Address Fax Number:
678-395-7702
Provider Enumeration Date:
03/20/2015

Additional Information

Authorized Official

Authorized Official Last Name:
SYED
Authorized Official First Name:
IRFAN
Authorized Official Middle Name:
ALI
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
678-691-3388

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  66330 , 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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