Provider Demographics
NPI:1578797627
Name:SOUTH GEORGIA PEDIATRICS, P.C.
Entity Type:Organization
Organization Name:SOUTH GEORGIA PEDIATRICS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RAO
Authorized Official - Middle Name:TULASI
Authorized Official - Last Name:IMMANENI
Authorized Official - Suffix:
Authorized Official - Credentials:MD, FAAP
Authorized Official - Phone:912-247-0409
Mailing Address - Street 1:PO BOX 1039
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30459-1039
Mailing Address - Country:US
Mailing Address - Phone:912-489-5437
Mailing Address - Fax:912-489-5550
Practice Address - Street 1:1230 BRAMPTON AVE
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-0849
Practice Address - Country:US
Practice Address - Phone:912-489-5437
Practice Address - Fax:912-489-5550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-05
Last Update Date:2009-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA044756174400000X
GAAPPLIED FOR261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty