1932321361 NPI number — DR. AMENA M IMTIAZ MD

Table of content: DR. AMENA M IMTIAZ MD (NPI 1932321361)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932321361 NPI number — DR. AMENA M IMTIAZ MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
IMTIAZ
Provider First Name:
AMENA
Provider Middle Name:
M
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HASAN
Provider Other First Name:
AMENA
Provider Other Middle Name:
M
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1932321361
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/09/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3495 PIEDMONT ROAD, NE NINE PIEDMONT CENTER
Provider Second Line Business Mailing Address:
THE SOUTHEAST PERMANENTE MEDICAL GROUP, INC.
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30305-1736
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
205-587-9269
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20 GLENLAKE PARKWAY
Provider Second Line Business Practice Location Address:
KAISER PERMANENTE GLENLAKE MEDICAL CENTER
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30328
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
205-934-5038
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/03/2007

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: 2084N0400X , with the licence number:  064832 , 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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