Provider Demographics
NPI:1487365524
Name:MIDDLE GEORGIA ALLERGY ASTHMA AND IMMUNOLOGY CENTER LLC
Entity type:Organization
Organization Name:MIDDLE GEORGIA ALLERGY ASTHMA AND IMMUNOLOGY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:VENKAT
Authorized Official - Middle Name:DIVYA
Authorized Official - Last Name:VANGALA
Authorized Official - Suffix:
Authorized Official - Credentials:BS PSYCHOLOGY
Authorized Official - Phone:478-731-7235
Mailing Address - Street 1:3964 ELNORA DR
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-1825
Mailing Address - Country:US
Mailing Address - Phone:478-731-7235
Mailing Address - Fax:478-477-1779
Practice Address - Street 1:3964 ELNORA DR
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-1825
Practice Address - Country:US
Practice Address - Phone:478-477-1777
Practice Address - Fax:478-477-1779
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-09
Last Update Date:2022-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty