Healthcare Provider Details

I. General information

NPI: 1376562231
Provider Name (Legal Business Name): MARANDAPALLI R SRIDHARAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 10/22/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1348 WALTON WAY SUITE 5100
AUGUSTA GA
30901-5104
US

IV. Provider business mailing address

1348 WALTON WAY SUITE 5100
AUGUSTA GA
30901-5104
US

V. Phone/Fax

Practice location:
  • Phone: 706-724-8611
  • Fax: 706-724-6202
Mailing address:
  • Phone: 706-724-8611
  • Fax: 706-724-6202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number026392
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: