Basic Information
| Provider Information | |||||||||
| NPI: | 1023117272 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PATEL | ||||||||
| FirstName: | PULIN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 420 E 2ND AVE | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | ROME | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301613209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7065093000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 424 N MAIN ST | ||||||||
| Address2: | EMERGENCY DEPT | ||||||||
| City: | CEDARTOWN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301252644 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707482500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2006 | ||||||||
| LastUpdateDate: | 05/10/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 25191 | SC | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 059306 | GA | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207P00000X | 59306 | GA | N | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 251916 | 05 | SC | MEDICAID | BP7401363 | 01 | SC | FED DEA | OTHER | 576007863 | 01 | SC | CIGNA | OTHER | 540467491D | 05 | GA | MEDICAID | 20020669 | 01 | SC | SELECT HEALTH | OTHER | 576007863 | 01 | SC | UHC | OTHER |