Provider Demographics
NPI:1730501586
Name:PANDYA MEDICAL CENTER, INC
Entity Type:Organization
Organization Name:PANDYA MEDICAL CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TANYA
Authorized Official - Middle Name:O
Authorized Official - Last Name:PANDYA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:678-984-3151
Mailing Address - Street 1:7690 SAINT MARLO COUNTRY CLUB PKWY
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30097-1620
Mailing Address - Country:US
Mailing Address - Phone:678-984-3151
Mailing Address - Fax:
Practice Address - Street 1:3925 JOHNS CREEK CT STE A
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-6618
Practice Address - Country:US
Practice Address - Phone:770-709-6922
Practice Address - Fax:770-709-6910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-14
Last Update Date:2014-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA60956207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA60956OtherGA MEDICAL LICENSE