Healthcare Provider Details

I. General information

NPI: 1497183941
Provider Name (Legal Business Name): MY DOCTORS CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2013
Last Update Date: 01/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2320 ATLANTA HWY SUITE - 105
CUMMING GA
30040-6339
US

IV. Provider business mailing address

1754 MORNINGDALE CIR NONE
DULUTH GA
30097-5260
US

V. Phone/Fax

Practice location:
  • Phone: 678-473-0715
  • Fax:
Mailing address:
  • Phone: 678-473-0715
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number052826
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code2080P0214X
TaxonomyPediatric Pulmonology Physician
License Number63536
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number052826
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number052826
License Number StateGA
# 5
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number61431
License Number StateGA

VIII. Authorized Official

Name: KETAN GHIA
Title or Position: MANAGER
Credential:
Phone: 678-473-0715