Provider Demographics
NPI:1952343634
Name:LIVINGSTONE A. RASALAM, M.D. P.C.
Entity Type:Organization
Organization Name:LIVINGSTONE A. RASALAM, M.D. P.C.
Other - Org Name:PATHWAY WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LIVINGSTONE
Authorized Official - Middle Name:AJIT
Authorized Official - Last Name:RASALAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD,PC
Authorized Official - Phone:229-244-5000
Mailing Address - Street 1:3338L COUNTRY CLUB DR. STE. 1 PMB 150
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31605
Mailing Address - Country:US
Mailing Address - Phone:229-244-8288
Mailing Address - Fax:775-459-9129
Practice Address - Street 1:303 WOODROW WILSON DR
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-2537
Practice Address - Country:US
Practice Address - Phone:229-244-5000
Practice Address - Fax:229-244-0808
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIVINGSTONE A. RASALAM, M.D., P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-10
Last Update Date:2008-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA033437174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00475208CMedicaid
GA00475208CMedicaid
GAGRP3364Medicare ID - Type Unspecified