Healthcare Provider Details

I. General information

NPI: 1902928526
Provider Name (Legal Business Name): DRS CHANDRAKANTH & NIRMALA AMARAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 06/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 UVALDA ST
WAYCROSS GA
31501-4551
US

IV. Provider business mailing address

302 UVALDA ST
WAYCROSS GA
31501-4551
US

V. Phone/Fax

Practice location:
  • Phone: 912-285-2519
  • Fax: 912-284-2482
Mailing address:
  • Phone: 912-285-2519
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number159002
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number159002
License Number StateGA

VIII. Authorized Official

Name: CHANDRAKANTH AMARAM
Title or Position: MD
Credential: MD
Phone: 912-285-2519