=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932192788
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RITU KHANNA SHETTY MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/26/2005
-----------------------------------------------------
Last Update Date | 04/19/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11675 GREAT OAKS WAY STE 310
-----------------------------------------------------
City | ALPHARETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30022-2402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-250-4950
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6400 SHAFER CT STE 700
-----------------------------------------------------
City | ROSEMONT
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60018-4989
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 346-376-1702
-----------------------------------------------------
Fax | 224-532-2780
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | D0076820
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | H84123
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------