Healthcare Provider Details

I. General information

NPI: 1659531747
Provider Name (Legal Business Name): SHIRISH AMRUTIA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2008
Last Update Date: 08/18/2021
Certification Date: 08/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 NORTHSIDE CHEROKEE BLVD STE 130
CANTON GA
30115-8017
US

IV. Provider business mailing address

460 NORTHSIDE CHEROKEE BLVD STE 130
CANTON GA
30115-8017
US

V. Phone/Fax

Practice location:
  • Phone: 678-493-2527
  • Fax: 678-493-5608
Mailing address:
  • Phone: 516-665-1883
  • Fax: 678-493-5608

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberMT186542
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD434851
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number70034
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: