Provider Demographics
NPI:1235203811
Name:CONYERS MEDICAL CLINIC, PC
Entity Type:Organization
Organization Name:CONYERS MEDICAL CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:DR
Authorized Official - First Name:GANESH
Authorized Official - Middle Name:N
Authorized Official - Last Name:KINI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-922-1880
Mailing Address - Street 1:2601 SALEM RD SE
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30013-2127
Mailing Address - Country:US
Mailing Address - Phone:770-922-1880
Mailing Address - Fax:770-388-0201
Practice Address - Street 1:2601 SALEM RD SE
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30013-2127
Practice Address - Country:US
Practice Address - Phone:770-922-1880
Practice Address - Fax:770-388-0201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA30120207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP7047Medicare ID - Type UnspecifiedPROVIDER NO.