Basic Information
| Provider Information | |||||||||
| NPI: | 1528352598 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VENIGALLA | ||||||||
| FirstName: | PRAVEEN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 JEFFERSON ST | ||||||||
| Address2: | |||||||||
| City: | WHITEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284723634 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 129 N WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | SUMTER | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291504949 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8034346771 | ||||||||
| FaxNumber: | 8034343955 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2011 | ||||||||
| LastUpdateDate: | 10/24/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 52426 | SC | N | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | 2017-00547 | NC | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | NC3370 | 05 | SC | MEDICAID |