Provider Demographics
NPI:1720196520
Name:IMMANENI, RAO PRASAD (MD)
Entity Type:Individual
Prefix:
First Name:RAO
Middle Name:PRASAD
Last Name:IMMANENI
Suffix:
Gender:M
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: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
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2009-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA044756208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000798377AOtherPEACH STATE ID
GA2263921OtherUNITED HEALTH CARE
GA598970OtherBLUE CROSS BLUE SHIELD
GA1917290OtherCCN/FIRST HEALTH
GA5261615OtherCIGNA
GA0007241193OtherAETNA
GA000798377AMedicaid
GA10057735OtherAMERIGROUP PROVIDER ID
GA336225OtherWELLCARE
GAGRP3032Medicare ID - Type UnspecifiedMEDICARE GROUP #
GA2263921OtherUNITED HEALTH CARE
GA336225OtherWELLCARE