Provider Demographics
NPI:1932484854
Name:MCDONOUGH ADULT & PEDIATRIC MEDICAL CARE
Entity Type:Organization
Organization Name:MCDONOUGH ADULT & PEDIATRIC MEDICAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MUSHARAF
Authorized Official - Middle Name:
Authorized Official - Last Name:MOMIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-783-1767
Mailing Address - Street 1:130 EAGLE SPRING CT STE A
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-7252
Mailing Address - Country:US
Mailing Address - Phone:678-759-2278
Mailing Address - Fax:678-782-3260
Practice Address - Street 1:130 EAGLE SPRING CT STE A
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281
Practice Address - Country:US
Practice Address - Phone:678-759-2278
Practice Address - Fax:678-782-3260
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-12
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA055831207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA141851Medicare UPIN