=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720196520
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RAO PRASAD IMMANENI M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/29/2006
-----------------------------------------------------
Last Update Date | 05/11/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1230 BRAMPTON AVE
-----------------------------------------------------
City | STATESBORO
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30458-0849
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-489-5437
-----------------------------------------------------
Fax | 912-489-5550
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1039
-----------------------------------------------------
City | STATESBORO
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30459-1039
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-489-5437
-----------------------------------------------------
Fax | 912-489-5550
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 044756
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------