MEDICARE: DUNWOODY PROFESSIONAL MEDICAL 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	261Q00000X	Clinic/Center	042868	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1902064595
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DUNWOODY PROFESSIONAL MEDICAL INC

Provider Business Mailing Address
First Line	:	2803 PRIESTCLIFF DR
Second Line	:
City	:	SMYRNA
State	:	GA
Zip	:	30080-2195
Country	:	US
Telephone Number	:	770-455-8285
Fax Number	:	770-350-8973

Provider Business Practice Location Address
First Line	:	4480 N SHALLOWFORD RD
Second Line	:
City	:	DUNWOODY
State	:	GA
Zip	:	30338-6410
Country	:	US
Telephone Number	:	770-455-8285
Fax Number	:	770-350-8973

Authorized Official
Title or Position	:	CEO
Name	:	MOINUDDIN KAZI
Credential	:	MD
Telephone Number	:	770-455-8285

Provider Enumeration Date	:	05/30/2008
Last Update Date	:	12/08/2009

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