Basic Information
| Provider Information | |||||||||
| NPI: | 1578889556 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETER | ||||||||
| FirstName: | RENNY | ||||||||
| MiddleName: | VALAMPARAMBIL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5354 REYNOLDS ST | ||||||||
| Address2: | STE 424 | ||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314056007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9128195999 | ||||||||
| FaxNumber: | 9128195980 | ||||||||
| Practice Location | |||||||||
| Address1: | 5354 REYNOLDS ST | ||||||||
| Address2: | STE 424 | ||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314056007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9128195999 | ||||||||
| FaxNumber: | 9128195980 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2010 | ||||||||
| LastUpdateDate: | 10/18/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 072409 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 271710 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 003149090A | 05 | GA | MEDICAID |