Provider Demographics
NPI:1649579046
Name:MIDHA MEDICAL CLINIC
Entity Type:Organization
Organization Name:MIDHA MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:RAJU
Authorized Official - Middle Name:
Authorized Official - Last Name:MIDHA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-492-8665
Mailing Address - Street 1:1404 MONTREAL RD
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084
Mailing Address - Country:US
Mailing Address - Phone:770-492-8665
Mailing Address - Fax:770-492-8663
Practice Address - Street 1:1404 MONTREAL RD
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084
Practice Address - Country:US
Practice Address - Phone:770-492-8665
Practice Address - Fax:770-492-8663
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-24
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty