Healthcare Provider Details

I. General information

NPI: 1578797627
Provider Name (Legal Business Name): SOUTH GEORGIA PEDIATRICS, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2009
Last Update Date: 05/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1230 BRAMPTON AVE
STATESBORO GA
30458-0849
US

IV. Provider business mailing address

PO BOX 1039
STATESBORO GA
30459-1039
US

V. Phone/Fax

Practice location:
  • Phone: 912-489-5437
  • Fax: 912-489-5550
Mailing address:
  • Phone: 912-489-5437
  • Fax: 912-489-5550

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number044756
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberAPPLIED FOR
License Number StateGA

VIII. Authorized Official

Name: RAO TULASI IMMANENI
Title or Position: CEO
Credential: M.D., F.A.A.P.
Phone: 912-247-0409