1447567631 NPI number — DR SIRUVELLA MD PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447567631 NPI number — DR SIRUVELLA MD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DR SIRUVELLA MD PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1447567631
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/10/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
705 BREEDLOVE DR
Provider Second Line Business Mailing Address:
SUITE 800
Provider Business Mailing Address City Name:
MONROE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30655-2090
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-266-0567
Provider Business Mailing Address Fax Number:
770-266-0507

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
705 BREEDLOVE DR
Provider Second Line Business Practice Location Address:
SUITE 800
Provider Business Practice Location Address City Name:
MONROE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30655-2090
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-266-0567
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/09/2010

Additional Information

Authorized Official

Authorized Official Last Name:
SIRUVELLA
Authorized Official First Name:
SRIDEVI
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL DIRECTOR/PHYSICIAN
Authorized Official Telephone Number:
770-266-0567

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  057019 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 057019 . This is a "STATE MEDICAL LICENSE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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