Provider Demographics
NPI:1699044040
Name:KANDALLU R RAMESH, MD, PC
Entity Type:Organization
Organization Name:KANDALLU R RAMESH, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KANDALLU
Authorized Official - Middle Name:R
Authorized Official - Last Name:RAMESH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-287-1297
Mailing Address - Street 1:101 DARLING AVE
Mailing Address - Street 2:
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31501-5219
Mailing Address - Country:US
Mailing Address - Phone:912-287-1297
Mailing Address - Fax:912-283-6897
Practice Address - Street 1:101 DARLING AVE
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-5219
Practice Address - Country:US
Practice Address - Phone:912-287-1297
Practice Address - Fax:912-283-6897
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-14
Last Update Date:2011-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA34928207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00483062BMedicaid
GAD85361Medicare UPIN
GA00483062BMedicaid