=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801256326
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE CENTER FOR INTERNAL & INTEGRATIVE MEDICINE, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/25/2016
-----------------------------------------------------
Last Update Date | 02/25/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 401 S MAIN ST STE B3
-----------------------------------------------------
City | ALPHARETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30009-1958
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-836-9906
-----------------------------------------------------
Fax | 470-545-4768
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 401 S MAIN ST STE B3
-----------------------------------------------------
City | ALPHARETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30009-1958
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-836-9906
-----------------------------------------------------
Fax | 470-545-4768
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FOUNDER/CEO
-----------------------------------------------------
Name | DR. EDUARD FATAKHOV
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 770-256-7069
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RB0002X
-----------------------------------------------------
Taxonomy Name | Obesity Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number | 71068
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------