Organization
SOUTH GEORGIA PEDIATRICS, P.C.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
RAO TULASI IMMANENI M.D., F.A.A.P. (CEO)
(912) 247-0409
Entity
Organization
Contact information
Practice address
1230 BRAMPTON AVE, STATESBORO, GA 30458-0849
(912) 489-5437
(912) 489-5550
Mailing address
PO BOX 1039, STATESBORO, GA 30459-1039
(912) 489-5437
(912) 489-5550
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
044756
GA
261Q00000X
Clinic/Center
APPLIED FOR
GA
Other
Enumeration date
05/05/2009
Last updated
05/07/2009
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