1992929186 NPI number — DOUGLAS MEDICAL GROUP

Table of content: (NPI 1992929186)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992929186 NPI number — DOUGLAS MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DOUGLAS MEDICAL GROUP
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:
6
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:
1992929186
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/08/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6025 PROFESSIONAL PKWY
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
DOUGLASVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30134-5609
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-949-0555
Provider Business Mailing Address Fax Number:
770-949-4424

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6025 PROFESSIONAL PKWY
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
DOUGLASVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30134-5609
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-949-0555
Provider Business Practice Location Address Fax Number:
770-949-4424
Provider Enumeration Date:
04/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SHROFF
Authorized Official First Name:
GIRISH
Authorized Official Middle Name:
I
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
770-949-0555

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  027530 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 061515 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: RN167533 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: RN095208 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 019103 , 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: 00305302B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 452595412D , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000137827B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 002528159A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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