1710327424 NPI number — SHRAVANI SURAKANTI M.D.

Table of content: SHRAVANI SURAKANTI M.D. (NPI 1710327424)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710327424 NPI number — SHRAVANI SURAKANTI M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SURAKANTI
Provider First Name:
SHRAVANI
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

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:
1710327424
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/07/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4155 ESSEN LN
Provider Second Line Business Mailing Address:
APT 135
Provider Business Mailing Address City Name:
BATON ROUGE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70809-2150
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
765-366-5056
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8585 PICARDY AVE
Provider Second Line Business Practice Location Address:
SUITE 414
Provider Business Practice Location Address City Name:
BATON ROUGE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70809-3748
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-763-4764
Provider Business Practice Location Address Fax Number:
225-763-4549
Provider Enumeration Date:
06/26/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  MD.303223 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2426966 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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