MEDICARE: DR. ANILA QIDWAI MD

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	207Q00000X	Family Medicine Physician	065787	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0-634-383-4	OTHER	CA	ECFMG#
2	065787	OTHER	GA	GEORGIA LISCENCE

General Provider Information

NPI Number	:	1982614665
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ANILA QIDWAI MD

Provider Business Mailing Address
First Line	:	1570 OLD ALABAMA RD
Second Line	:	SUITE #105
City	:	ROSWELL
State	:	GA
Zip	:	30076-2108
Country	:	US
Telephone Number	:	770-676-6838
Fax Number	:	770-676-6840

Provider Business Practice Location Address
First Line	:	1570 OLD ALABAMA RD
Second Line	:	SUITE#105
City	:	ROSWELL
State	:	GA
Zip	:	30076-2108
Country	:	US
Telephone Number	:	770-676-6838
Fax Number	:	770-676-6840

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/08/2006
Last Update Date	:	04/11/2012

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Directions to “ DR. ANILA QIDWAI MD” Practice Location

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