Healthcare Provider Details

I. General information

NPI: 1316113897
Provider Name (Legal Business Name): PRAVEEN MANNAM M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2008
Last Update Date: 12/10/2024
Certification Date: 11/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3511 W MARKET ST STE 100
GREENSBORO NC
27403-4444
US

IV. Provider business mailing address

PO BOX 745040
ATLANTA GA
30374-5040
US

V. Phone/Fax

Practice location:
  • Phone: 336-522-8999
  • Fax: 336-522-8998
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number2016-00544
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number2016-00544
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: