1407943228 NPI number — BRUNDA REVANNA, MD

Table of content: (NPI 1407943228)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407943228 NPI number — BRUNDA REVANNA, MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRUNDA REVANNA, MD
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407943228
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/24/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
950 EAGLES LANDING PKWY #321
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STOCKBRIDGE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30281
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-432-4755
Provider Business Mailing Address Fax Number:
678-432-4753

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1465 A 1ST AVE SW STE C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36265
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-432-4755
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
REVANNA
Authorized Official First Name:
BRUNDA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
678-432-4755

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 009930945 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com