Healthcare Provider Details

I. General information

NPI: 1023403144
Provider Name (Legal Business Name): SRIVIDYA SRINIVASAMAHARAJ M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2015
Last Update Date: 10/12/2021
Certification Date: 10/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1831 5TH AVE
COLUMBUS GA
31904-8915
US

IV. Provider business mailing address

PO BOX 117339
ATLANTA GA
30368-7339
US

V. Phone/Fax

Practice location:
  • Phone: 706-320-8780
  • Fax: 706-320-8721
Mailing address:
  • Phone: 770-801-2500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number87471
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: