Provider Demographics
NPI:1285698258
Name:AMIN, ANSUYA (MD)
Entity type:Individual
Prefix:
First Name:ANSUYA
Middle Name:
Last Name:AMIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 BOULDER WAY
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075-4160
Mailing Address - Country:US
Mailing Address - Phone:865-985-7186
Mailing Address - Fax:865-692-3390
Practice Address - Street 1:710 CENTER ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901-1527
Practice Address - Country:US
Practice Address - Phone:706-571-1064
Practice Address - Fax:706-571-1986
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0516102085R0202X
KY187642085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
C74402Medicare UPIN
GA30BDLHTMedicare ID - Type Unspecified