Basic Information
| Provider Information | |||||||||
| NPI: | 1306057914 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PAVULURI | ||||||||
| FirstName: | ANURADHA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2490 RIVERSIDE DR | ||||||||
| Address2: | STE B | ||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312041787 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4786336633 | ||||||||
| FaxNumber: | 4786334295 | ||||||||
| Practice Location | |||||||||
| Address1: | 777 HEMLOCK ST | ||||||||
| Address2: | MSC 10 | ||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312012102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4786337140 | ||||||||
| FaxNumber: | 4786334295 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2007 | ||||||||
| LastUpdateDate: | 07/13/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | ABO 797 603 | NY | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 4301094423 | MI | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 070401 | GA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1046519 | 01 | MI | MCLAREN | OTHER | 200000021987 | 01 | MI | PHP COMMERCIAL | OTHER | 1046518 | 01 | MI | MCLAREN | OTHER | 070401 | 01 | GA | GA LICENSE | OTHER | 3502900092 | 01 | MI | BCBSM | OTHER |