=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558184002
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AMERICAN INTEGRATIVE MEDICINE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/04/2024
-----------------------------------------------------
Last Update Date | 11/04/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 767 PEACHTREE PKWY STE 4
-----------------------------------------------------
City | CUMMING
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30041-9348
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-208-3460
-----------------------------------------------------
Fax | 678-374-4902
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 767 PEACHTREE PKWY STE 4
-----------------------------------------------------
City | CUMMING
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30041-9348
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-208-3460
-----------------------------------------------------
Fax | 678-374-4902
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF MEDICAL OFFICER
-----------------------------------------------------
Name | JAYKRISHNA DARJI
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 678-208-3460
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QA0401X
-----------------------------------------------------
Taxonomy Name | Addiction Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------