Healthcare Provider Details

I. General information

NPI: 1487365524
Provider Name (Legal Business Name): MIDDLE GEORGIA ALLERGY ASTHMA AND IMMUNOLOGY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2022
Last Update Date: 12/16/2022
Certification Date: 12/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3964 ELNORA DR
MACON GA
31210-1825
US

IV. Provider business mailing address

3964 ELNORA DR
MACON GA
31210-1825
US

V. Phone/Fax

Practice location:
  • Phone: 478-477-1777
  • Fax: 478-477-1779
Mailing address:
  • Phone: 478-731-7235
  • Fax: 478-477-1779

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. VENKAT DIVYA VANGALA
Title or Position: PRACTICE MANAGER
Credential: BS PSYCHOLOGY
Phone: 478-731-7235