Basic Information
| Provider Information | |||||||||
| NPI: | 1356533145 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NINAN | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | JOHN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1835 SAVOY DR STE 300 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303411071 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6785666995 | ||||||||
| FaxNumber: | 6785660346 | ||||||||
| Practice Location | |||||||||
| Address1: | 6300 HOSPITAL PKWY STE 300 | ||||||||
| Address2: | |||||||||
| City: | JOHNS CREEK | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300971982 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7706238965 | ||||||||
| FaxNumber: | 7706234018 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2007 | ||||||||
| LastUpdateDate: | 08/20/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207RH0003X | 058551 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207RH0003X | 43128 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207RH0003X | N7955 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | G10127A | 01 | GA | MEDICARE PTAN | OTHER | 003158193C | 05 | GA | MEDICAID | 003158193D | 05 | GA | MEDICAID |