Basic Information
| Provider Information | |||||||||
| NPI: | 1790849495 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VEMURI | ||||||||
| FirstName: | KAVITHA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5410 MARYLAND WAY | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370275064 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153775670 | ||||||||
| FaxNumber: | 6153771678 | ||||||||
| Practice Location | |||||||||
| Address1: | 6501 PEAKE RD | ||||||||
| Address2: | SUITE 700 | ||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312108042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4784769285 | ||||||||
| FaxNumber: | 4784749034 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2006 | ||||||||
| LastUpdateDate: | 02/02/2011 | ||||||||
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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 | 207R00000X | 055350 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 622559586A | 05 | GA | MEDICAID |