Provider Demographics
NPI:1528017332
Name:BADARUDDIN, ROSE BENIGNA (MD)
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:BENIGNA
Last Name:BADARUDDIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 TREE LANE RD
Mailing Address - Street 2:SUITE 160
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-6782
Mailing Address - Country:US
Mailing Address - Phone:770-979-3989
Mailing Address - Fax:770-979-4330
Practice Address - Street 1:1700 TREE LANE RD
Practice Address - Street 2:SUITE 160
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-6782
Practice Address - Country:US
Practice Address - Phone:770-979-3989
Practice Address - Fax:770-979-4330
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA020401208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000553616Medicaid
GA000553616Medicaid