1619026150 NPI number — HANIF BOGHANI MD

Table of content: HANIF BOGHANI MD (NPI 1619026150)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619026150 NPI number — HANIF BOGHANI MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOGHANI
Provider First Name:
HANIF
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MOHAMMADI
Provider Other First Name:
MUHAMMAD
Provider Other Middle Name:
HANIF
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1619026150
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/09/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 467071
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31146-7071
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-939-2020
Provider Business Mailing Address Fax Number:
770-939-6688

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1462 MONTREAL RD
Provider Second Line Business Practice Location Address:
SUITE 214
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:
770-939-2020
Provider Business Practice Location Address Fax Number:
770-939-6688
Provider Enumeration Date:
01/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  047929 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208M00000X , with the licence number: 047929 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 435309113A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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