Provider Demographics
NPI:1508914367
Name:INTERNAL MEDICINE ASSOCIATES OF STATESBORO II, PC
Entity Type:Organization
Organization Name:INTERNAL MEDICINE ASSOCIATES OF STATESBORO II, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SARAJU
Authorized Official - Middle Name:C
Authorized Official - Last Name:DALSANIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-681-8488
Mailing Address - Street 1:1601 FAIR ROAD
Mailing Address - Street 2:SUITE 700
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-0800
Mailing Address - Country:US
Mailing Address - Phone:912-681-8488
Mailing Address - Fax:912-681-4337
Practice Address - Street 1:1601 FAIR RD
Practice Address - Street 2:SUITE 700
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-1698
Practice Address - Country:US
Practice Address - Phone:912-681-8488
Practice Address - Fax:912-681-4337
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2010-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA045196207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA602993737AMedicaid
GA602993737AMedicaid
GAG71528Medicare UPIN