=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629724752
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WEST ATLANTA PRIMARY CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/28/2022
-----------------------------------------------------
Last Update Date | 03/25/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4904 TIMBER RIDGE DR STE 102
-----------------------------------------------------
City | DOUGLASVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30135-1831
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-521-0935
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4904 TIMBER RIDGE DR STE 102
-----------------------------------------------------
City | DOUGLASVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30135-1831
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-521-0935
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. SHIVAM DESAI
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 678-401-4597
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------