Healthcare Provider Details

I. General information

NPI: 1912288457
Provider Name (Legal Business Name): SOUTH ATLANTA MEDICAL CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2011
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6525 PROFESSIONAL PL STE B
RIVERDALE GA
30274-2519
US

IV. Provider business mailing address

6525 PROFESSIONAL PL STE B
RIVERDALE GA
30274-2519
US

V. Phone/Fax

Practice location:
  • Phone: 404-254-5496
  • Fax: 404-254-5829
Mailing address:
  • Phone: 404-254-5496
  • Fax: 404-254-5829

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number20280
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20280
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number20280
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number20280
License Number StateGA
# 5
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number20280
License Number StateGA
# 6
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number20280
License Number StateGA
# 7
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number61081
License Number StateGA
# 8
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number20280
License Number StateGA

VIII. Authorized Official

Name: TUSHAR NARROTTAM
Title or Position: MANAGER
Credential:
Phone: 404-867-3584