Healthcare Provider Details

I. General information

NPI: 1992014872
Provider Name (Legal Business Name): CUMMING RHEUMATOLOGY AND ARTHRITIS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2010
Last Update Date: 01/21/2020
Certification Date: 01/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3970 DEPUTY BILL CANTRELL MEM STE 203
CUMMING GA
30040-3004
US

IV. Provider business mailing address

3970 DEPUTY BILL CANTRELL MEM STE 203
CUMMING GA
30040-5962
US

V. Phone/Fax

Practice location:
  • Phone: 770-887-5159
  • Fax: 770-887-9496
Mailing address:
  • Phone: 770-887-5159
  • Fax: 770-887-9496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number62253
License Number StateGA

VIII. Authorized Official

Name: DR. JAGINDRA NATH MANGRU
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 770-887-5159