=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760981609
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MICHELLE ZEANAH MD PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/06/2018
-----------------------------------------------------
Last Update Date | 12/28/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 406 SAVANNAH AVE
-----------------------------------------------------
City | STATESBORO
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30458-5102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-489-4379
-----------------------------------------------------
Fax | 912-681-4379
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 406 SAVANNAH AVE
-----------------------------------------------------
City | STATESBORO
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30458-5102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-489-4379
-----------------------------------------------------
Fax | 912-681-4379
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MICHELLE REYNOLDS ZEANAH
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 912-489-4379
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number | 56388
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------