Provider Demographics
NPI:1992929186
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:2007-04-12
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA019103207R00000X
GA027530207R00000X
GA061515207R00000X
GARN167533363L00000X
GARN095208363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00305302BMedicaid
GA452595412DMedicaid
GA000137827BMedicaid
GA002528159AMedicaid
GA00305302BMedicaid
GA202606854AMedicare ID - Type UnspecifiedDR. DESAI
GA000137827BMedicaid
GA11SCHFFMedicare PIN
GAQ07278Medicare UPIN
GA118528586AMedicare ID - Type UnspecifiedDR. SHROFF
GAGRP1283Medicare ID - Type UnspecifiedGROUP NUMBER
GA202I509821Medicare PIN
GAD39735Medicare UPIN
GA002528159AMedicaid
GA452595412DMedicaid