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General NPI Number Information
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NPI Number | 1437428331
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Entity Type | Organization
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Legal Business Name | PEACHTREE PRIMARY CARE PC
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Dates
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Enumeration Date | 12/21/2011
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Last Update Date | 05/04/2012
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Provider Practice Location Address
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Address Line | 1570 OLD ALABAMA RD
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City | ROSWELL
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State | GA
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Zip | 30076-2107
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Country | US
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Telephone | 770-676-6838
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Fax | 770-676-6840
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Provider Business Mailing Address
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Address Line | 1570 OLD ALABAMA RD SUITE 105
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City | ROSWELL
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State | GA
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Zip | 30076-2107
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Country | US
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Telephone | 770-676-6838
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Fax | 770-676-6840
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Authorized Official
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Title or Position | OWNER
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Name | DR. ANILA H QIDWAI
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Credential | MD
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Telephone | 770-676-6838
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 065787
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License Number State | GA
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