Provider Demographics
NPI:1629277017
Name:ATLANTA CARDIOLOGY PRIMARY CARE PC
Entity Type:Organization
Organization Name:ATLANTA CARDIOLOGY PRIMARY CARE PC
Other - Org Name:ATLANTA CARDIOLOGY AND PRIMARY CARE PC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BOBBY
Authorized Official - Middle Name:V
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-296-1130
Mailing Address - Street 1:3562 HABERSHAM AT NORTHLAKE
Mailing Address - Street 2:BUILDING J
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-4009
Mailing Address - Country:US
Mailing Address - Phone:404-296-1130
Mailing Address - Fax:404-296-1132
Practice Address - Street 1:3562 HABERSHAM AT NORTHLAKE
Practice Address - Street 2:BUILDING J
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-4009
Practice Address - Country:US
Practice Address - Phone:404-296-1130
Practice Address - Fax:404-296-1132
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-16
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA047506207R00000X
GA037251207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP2782Medicare Oscar/Certification