East Alabama Neurology, Inc.

Contacts

Phone	+1 334-887-0955
Fax	3348870964

Authorized person

Name	DR. KRISHNA KISHORE CHIVUKULA
Role	PHYSICIAN
Phone	3348870955

Taxonomy

Taxonomy Code	174400000X - Specialist
License Number	3874
State	AL
Is Primary	Yes

Other Provider Identifiers

Issuer	MEDICAID
Number	52906460
State	AL

File	View Page
Three-digit plan number (PN)	002
Effective date of plan	2014-01-01
Business code	621111
Sponsor’s telephone number	3348870955
Plan sponsor’s address	3120 FREDERICK ROAD SUITE I, OPELIKA, AL, 36801

Signature of

Role	Plan administrator
Date	2022-10-04
Name of individual signing	KRISHNA CHIVUKULA

File	View Page
Three-digit plan number (PN)	002
Effective date of plan	2014-01-01
Business code	621111
Sponsor’s telephone number	3348870955
Plan sponsor’s address	3120 FREDERICK ROAD SUITE I, OPELIKA, AL, 36801

Signature of

Role	Plan administrator
Date	2021-02-05
Name of individual signing	KRISHNA CHIVUKULA

File	View Page
Three-digit plan number (PN)	002
Effective date of plan	2014-01-01
Business code	621111
Sponsor’s telephone number	3348870955
Plan sponsor’s address	3120 FREDERICK ROAD SUITE I, OPELIKA, AL, 36801

Signature of

Role	Plan administrator
Date	2020-06-03
Name of individual signing	KRISHNA CHIVUKULA

File	View Page
Three-digit plan number (PN)	002
Effective date of plan	2014-01-01
Business code	621111
Sponsor’s telephone number	3348870955
Plan sponsor’s address	3120 FREDERICK ROAD SUITE I, OPELIKA, AL, 36801

Signature of

Role	Plan administrator
Date	2019-09-24
Name of individual signing	KRISHNA CHIVUKULA

File	View Page
Three-digit plan number (PN)	002
Effective date of plan	2014-01-01
Business code	621111
Sponsor’s telephone number	3348870955
Plan sponsor’s address	3120 FREDERICK ROAD SUITE I, OPELIKA, AL, 36801

Signature of

Role	Plan administrator
Date	2018-07-27
Name of individual signing	KRISHNA CHIVUKULA

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2005-01-01
Business code	621111
Sponsor’s telephone number	3348870955
Plan sponsor’s address	3120 FREDERICK RD STE I, OPELIKA, AL, 368017135

Signature of

Role	Plan administrator
Date	2015-07-01
Name of individual signing	KRISHNA CHIVUKULA

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2005-01-01
Business code	621111
Sponsor’s telephone number	3348870955
Plan sponsor’s address	3120 FREDERICK RD STE I, OPELIKA, AL, 368017135

Signature of

Role	Plan administrator
Date	2014-09-04
Name of individual signing	KRISHNA CHIVUKULA

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2005-01-01
Business code	621111
Sponsor’s telephone number	3348870955
Plan sponsor’s address	3120 FREDERICK RD STE I, OPELIKA, AL, 368017135

Signature of

Role	Plan administrator
Date	2013-07-22
Name of individual signing	KRISHNA CHIVUKULA