MEDICARE: SOUTH ATLANTA MEDICAL GROUP, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	CHIR007845	GA
2	207R00000X	Internal Medicine Physician	036662	GA

General Provider Information

NPI Number	:	1841578853
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH ATLANTA MEDICAL GROUP, INC

Provider Business Mailing Address
First Line	:	2643 CALDWELL RD NE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30319-3118
Country	:	US
Telephone Number	:	678-328-0577
Fax Number	:

Provider Business Practice Location Address
First Line	:	2643 CALDWELL RD NE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30319-3118
Country	:	US
Telephone Number	:	678-328-0577
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	DR. RAKESH KOTHARI
Credential	:	DC
Telephone Number	:	678-328-0577

Provider Enumeration Date	:	07/25/2011
Last Update Date	:	01/10/2012

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