1750756235 NPI number — DR. SRINIVAS BOLUGODDU RAO M.D

Table of content: JOSINA SILVA LMT (NPI 1528482841)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750756235 NPI number — DR. SRINIVAS BOLUGODDU RAO M.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RAO
Provider First Name:
SRINIVAS
Provider Middle Name:
BOLUGODDU
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D
Provider Gender Code:
M

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:
1750756235
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/02/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
327 BEACH 19TH STREET
Provider Second Line Business Mailing Address:
ST JOHNS MEDICAL SERVICES, PC
Provider Business Mailing Address City Name:
FAR ROCKAWAY
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11691-4423
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-869-7919
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
521 BEACH 20TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAR ROCKAWAY
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11691-3645
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-869-8822
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/09/2015

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: 2084P0800X , with the licence number:  301622 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 301622 . This is a "NYS LICENSE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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