Basic Information
| Provider Information | |||||||||
| NPI: | 1407943228 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BRUNDA REVANNA, MD | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | JACKSONVILLE FAMILY HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 950 EAGLES LANDING PKWY #321 | ||||||||
| Address2: | |||||||||
| City: | STOCKBRIDGE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30281 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6784324755 | ||||||||
| FaxNumber: | 6784324753 | ||||||||
| Practice Location | |||||||||
| Address1: | 1465 A 1ST AVE SW STE C | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 36265 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6784324755 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 06/24/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | REVANNA | ||||||||
| AuthorizedOfficialFirstName: | BRUNDA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6784324755 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 009930945 | 05 | AL | MEDICAID |