Basic Information
| Provider Information | |||||||||
| NPI: | 1366977647 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MEHTA | ||||||||
| FirstName: | MITALI | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 44 KROG ST NE UNIT 435 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303072650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7066311139 | ||||||||
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| Practice Location | |||||||||
| Address1: | 350 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312173838 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4787657000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2017 | ||||||||
| LastUpdateDate: | 08/04/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 86023 | GA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.