MEDICARE: GWINNETT CLINIC, LTD

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	173000000X	Legal Medicine
2	261QM1300X	Multi-Specialty Clinic/Center
3	2085R0202X	Diagnostic Radiology Physician

General Provider Information

NPI Number	:	1952676496
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GWINNETT CLINIC, LTD

Provider Business Mailing Address
First Line	:	10600 MEDLOCK BRIDGE RD
Second Line	:
City	:	DULUTH
State	:	GA
Zip	:	30097-8404
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3475 PIEDMONT RD NE STE 1150
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30305-3003
Country	:	US
Telephone Number	:	770-995-3300
Fax Number	:	770-995-3307

Authorized Official
Title or Position	:	AUTHORIZED OFFICIAL
Name	:	DEEP SHAH
Credential	:	MD, MSC
Telephone Number	:	770-995-3300

Provider Enumeration Date	:	03/16/2012
Last Update Date	:	01/25/2023

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