Healthcare Provider Details

I. General information

NPI: 1013931617
Provider Name (Legal Business Name): MICHELLE R ZEANAH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 09/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

406 SAVANNAH AVE
STATESBORO GA
30458-5102
US

IV. Provider business mailing address

406 SAVANNAH AVE
STATESBORO GA
30458-5102
US

V. Phone/Fax

Practice location:
  • Phone: 912-489-4379
  • Fax: 912-681-4379
Mailing address:
  • Phone: 912-489-4379
  • Fax: 912-681-4379

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number056388
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License Number56388
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: