Healthcare Provider Details

I. General information

NPI: 1619076866
Provider Name (Legal Business Name): SUDHA SAGAR BENNURI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 03/14/2023
Certification Date: 03/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2701 20TH AVENUE
NORTHPORT AL
35476-3832
US

IV. Provider business mailing address

2701 20TH AVENUE
NORTHPORT AL
35476-3832
US

V. Phone/Fax

Practice location:
  • Phone: 205-333-5900
  • Fax: 205-333-6090
Mailing address:
  • Phone: 205-333-8900
  • Fax: 205-333-6090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number22564
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: