=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023003001
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHIRDI MEDICAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/15/2005
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1751 W ROMNEYA DR
-----------------------------------------------------
City | ANAHEIM
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92801-1815
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-776-3180
-----------------------------------------------------
Fax | 714-991-1932
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1751 W ROMNEYA DR
-----------------------------------------------------
City | ANAHEIM
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92801-1815
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-776-3180
-----------------------------------------------------
Fax | 714-991-1932
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | AMIRTHA AJIT
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 714-776-3180
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | A56179
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------