Provider Demographics
NPI:1467524330
Name:WEST COBB INTERNAL MEDICINE PC
Entity Type:Organization
Organization Name:WEST COBB INTERNAL MEDICINE PC
Other - Org Name:CHIDAMBARAM RAGHAVAN MD
Other - Org Type:Other Name
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CHIDAMBARAM
Authorized Official - Middle Name:
Authorized Official - Last Name:RAGHAVAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-218-1880
Mailing Address - Street 1:5041 DALLAS HIGHWAY
Mailing Address - Street 2:BLDG 2 SUITE E WEST COBB INTERNAL MEDICINE PC
Mailing Address - City:POWDER SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30127
Mailing Address - Country:US
Mailing Address - Phone:770-218-1880
Mailing Address - Fax:770-218-1088
Practice Address - Street 1:5041 DALLAS HWY
Practice Address - Street 2:BLDG 2 SUITE E WEST COBB INTERNAL MEDICINE PC
Practice Address - City:POWDER SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30127
Practice Address - Country:US
Practice Address - Phone:770-218-1880
Practice Address - Fax:770-218-1088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA38709207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00626117AMedicaid
GA4562104OtherAETNA
GA0400005OtherUNITED HEALTHCARE
GA617437OtherBCBS
GA00626117AMedicaid
GA4562104OtherAETNA
GA11BDMWQMedicare PIN