Healthcare Provider Details

I. General information

NPI: 1740285212
Provider Name (Legal Business Name): KUSUMA RAO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2005
Last Update Date: 12/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

703 S 9TH ST
GRIFFIN GA
30224-4820
US

IV. Provider business mailing address

PO BOX 758
GRIFFIN GA
30224-0020
US

V. Phone/Fax

Practice location:
  • Phone: 770-227-2727
  • Fax: 770-227-1276
Mailing address:
  • Phone: 770-227-2727
  • Fax: 770-227-1276

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number027146
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: