Provider Demographics
NPI:1861530016
Name:NEUROLOGY SOUTH PC
Entity type:Organization
Organization Name:NEUROLOGY SOUTH PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RAGHURAM
Authorized Official - Middle Name:
Authorized Official - Last Name:KOLANU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-474-4875
Mailing Address - Street 1:PO BOX 2877
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281
Mailing Address - Country:US
Mailing Address - Phone:770-474-4875
Mailing Address - Fax:770-474-1469
Practice Address - Street 1:1050 EAGLES LANDING PKWY
Practice Address - Street 2:STE 203
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281
Practice Address - Country:US
Practice Address - Phone:770-474-4875
Practice Address - Fax:770-474-1469
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GRP6912Medicare ID - Type Unspecified