Provider Demographics
NPI:1104886316
Name:DOUGLAS MEDICAL GROUP
Entity type:Organization
Organization Name:DOUGLAS MEDICAL GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GIRISH
Authorized Official - Middle Name:I
Authorized Official - Last Name:SHROFF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-949-0555
Mailing Address - Street 1:6025 PROFESSIONAL PKWY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30134-5609
Mailing Address - Country:US
Mailing Address - Phone:770-949-0555
Mailing Address - Fax:770-949-4424
Practice Address - Street 1:6025 PROFESSIONAL PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134-5609
Practice Address - Country:US
Practice Address - Phone:770-949-0555
Practice Address - Fax:770-949-4424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA027530174400000X
GA038955174400000X
GARN070145174400000X
GA019103174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00305302BMedicaid
GAF29978Medicare UPIN
GA00305302BMedicaid
GAP78974Medicare UPIN
GAD30822Medicare UPIN
GAD39735Medicare UPIN
GA50BBGNJMedicare ID - Type Unspecified