Healthcare Provider Details

I. General information

NPI: 1255562567
Provider Name (Legal Business Name): CELESTINE AMUCHIE NNAETO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2009
Last Update Date: 03/08/2021
Certification Date: 03/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2227 US HIGHWAY 41 N
TIFTON GA
31794-2749
US

IV. Provider business mailing address

907 18TH ST E STE 400
TIFTON GA
31794-3684
US

V. Phone/Fax

Practice location:
  • Phone: 229-386-5222
  • Fax: 229-382-6161
Mailing address:
  • Phone: 229-353-3422
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberMT196131
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207RS0010X
TaxonomySports Medicine (Internal Medicine) Physician
License Number080012
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: