Healthcare Provider Details

I. General information

NPI: 1710168539
Provider Name (Legal Business Name): GERIATRIC MEDICINE OF ATLANTA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2007
Last Update Date: 07/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1019 WINDING RIDGE CT
ATLANTA GA
30338-3949
US

IV. Provider business mailing address

PO BOX 3253
ALPHARETTA GA
30023-3253
US

V. Phone/Fax

Practice location:
  • Phone: 770-888-2524
  • Fax: 770-888-2510
Mailing address:
  • Phone: 770-888-2524
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number48998
License Number StateGA

VIII. Authorized Official

Name: MOUNIR DARRADJI
Title or Position: PRESIDENT
Credential: MD
Phone: 770-888-2524