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General NPI Number Information
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NPI Number | 1487365524
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Entity Type | Organization
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Legal Business Name | MIDDLE GEORGIA ALLERGY ASTHMA AND IMMUNOLOGY CENTER LLC
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Dates
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Enumeration Date | 12/09/2022
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Last Update Date | 12/16/2022
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Provider Practice Location Address
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Address Line | 3964 ELNORA DR
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City | MACON
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State | GA
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Zip | 31210-1825
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Country | US
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Telephone | 478-477-1777
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Fax | 478-477-1779
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Provider Business Mailing Address
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Address Line | 3964 ELNORA DR
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City | MACON
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State | GA
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Zip | 31210-1825
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Country | US
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Telephone | 478-731-7235
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Fax | 478-477-1779
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Authorized Official
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Title or Position | PRACTICE MANAGER
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Name | MRS. VENKAT DIVYA VANGALA
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Credential | BS PSYCHOLOGY
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Telephone | 478-731-7235
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207K00000X
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Taxonomy Name | Allergy & Immunology Physician
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License Number |
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License Number State |
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