Individual
RAO PRASAD IMMANENI
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
M.D.
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
208000000X
Pediatrics Physician
Primary
044756
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0007241193
AETNA
GA
01
—
000798377A
PEACH STATE ID
GA
05
—
000798377A
—
GA
01
—
10057735
AMERIGROUP PROVIDER ID
GA
01
—
1917290
CCN/FIRST HEALTH
GA
01
—
2263921
UNITED HEALTH CARE
GA
01
—
336225
WELLCARE
GA
01
—
5261615
CIGNA
GA
01
—
598970
BLUE CROSS BLUE SHIELD
GA
Enumeration date
08/29/2006
Last updated
05/11/2009
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