Provider Demographics
NPI:1376652453
Name:MAMMEN, ANNAMMA T (MD)
Entity Type:Individual
Prefix:
First Name:ANNAMMA
Middle Name:T
Last Name:MAMMEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1499 WALTON WAY
Mailing Address - Street 2:STE 1400
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30901-2602
Mailing Address - Country:US
Mailing Address - Phone:706-828-6410
Mailing Address - Fax:706-722-5187
Practice Address - Street 1:1120 15TH ST
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912-0004
Practice Address - Country:US
Practice Address - Phone:706-721-4588
Practice Address - Fax:706-721-7264
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2011-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA036652207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000544475AMedicaid
SCG36652Medicaid
GA000544475AMedicaid
GA08BDFZQMedicare ID - Type UnspecifiedGA MEDICARE #