=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578755351
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CENTER FOR INFECTIOUS DISEASES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/15/2007
-----------------------------------------------------
Last Update Date | 09/22/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 MARKET PLACE BLVD SUITE 207
-----------------------------------------------------
City | CARTERSVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30121-8718
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-721-6971
-----------------------------------------------------
Fax | 678-721-6974
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 MARKET PLACE BLVD SUITE 207
-----------------------------------------------------
City | CARTERSVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30121-8718
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-721-6971
-----------------------------------------------------
Fax | 678-721-6974
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | AMAN MONGIA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 678-721-6971
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 55685
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 055510
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------