Basic Information
| Provider Information | |||||||||
| NPI: | 1811040629 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REMOLLINO | ||||||||
| FirstName: | ANTONIO | ||||||||
| MiddleName: | GARCIA | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1909 US HIGHWAY 82 W STE 3&4 | ||||||||
| Address2: | |||||||||
| City: | TIFTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317938200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2294453509 | ||||||||
| FaxNumber: | 2294453513 | ||||||||
| Practice Location | |||||||||
| Address1: | 1909 US HIGHWAY 82 W STE 3&4 | ||||||||
| Address2: | |||||||||
| City: | TIFTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317938200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2294453509 | ||||||||
| FaxNumber: | 2294453513 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2007 | ||||||||
| LastUpdateDate: | 11/29/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0008X | MD158757 | OR | N | Allopathic & Osteopathic Physicians | Pediatrics | Neurodevelopmental Disabilities | 208000000X | MD158757 | OR | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 806866411E | 05 | GA | MEDICAID |