Healthcare Provider Details

I. General information

NPI: 1801151352
Provider Name (Legal Business Name): AVIRUP GUHA M.B.B.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2012
Last Update Date: 05/31/2022
Certification Date: 05/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 15TH ST
AUGUSTA GA
30912-4052
US

IV. Provider business mailing address

1120 15TH ST
AUGUSTA GA
30912-0004
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-3792
  • Fax:
Mailing address:
  • Phone: 706-721-2273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number35.132847
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number90156
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: