Healthcare Provider Details

I. General information

NPI: 1801199914
Provider Name (Legal Business Name): EDGEWOOD MEDICAL CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2010
Last Update Date: 12/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 EDGEWOOD AVE NE
ATLANTA GA
30303
US

IV. Provider business mailing address

212 EDGEWOOD AVE NE
ATLANTA GA
30303-3027
US

V. Phone/Fax

Practice location:
  • Phone: 404-246-0589
  • Fax: 404-688-2226
Mailing address:
  • Phone: 404-246-0589
  • Fax: 404-688-2226

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. GHOLAM REZA BAKHTIARI
Title or Position: PRESIDENT
Credential: PHARMD
Phone: 404-688-2211