Provider Demographics
NPI:1497183941
Name:MY DOCTORS CLINIC LLC
Entity Type:Organization
Organization Name:MY DOCTORS CLINIC LLC
Other - Org Name:PEACH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KETAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GHIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-473-0715
Mailing Address - Street 1:1754 MORNINGDALE CIR
Mailing Address - Street 2:NONE
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30097-5260
Mailing Address - Country:US
Mailing Address - Phone:678-473-0715
Mailing Address - Fax:
Practice Address - Street 1:2320 ATLANTA HWY
Practice Address - Street 2:SUITE - 105
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-6339
Practice Address - Country:US
Practice Address - Phone:678-473-0715
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-19
Last Update Date:2014-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA052826173000000X, 207R00000X, 207RS0012X
GA61431207Q00000X
GA635362080P0214X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No173000000XOther Service ProvidersLegal MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Multi-Specialty
No2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric PulmonologyGroup - Multi-Specialty