Healthcare Provider Details

I. General information

NPI: 1750338968
Provider Name (Legal Business Name): SRINIVAS R BRAMHADEVI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2006
Last Update Date: 10/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1497 LAFAYETTE STREET
LAGRANGE GA
30241-2552
US

IV. Provider business mailing address

1497 LAFAYETTE STREET
LAGRANGE GA
30241-2552
US

V. Phone/Fax

Practice location:
  • Phone: 706-880-7335
  • Fax: 706-812-2403
Mailing address:
  • Phone: 68-807-3357
  • Fax: 706-812-2403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number45129
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number61946
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: