Healthcare Provider Details

I. General information

NPI: 1477880714
Provider Name (Legal Business Name): SRINIVAS S GANJI M.D. A PROF MEDICAL CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2009
Last Update Date: 11/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 HIGHWAY PARK PLAZA
COVINGTON LA
70433
US

IV. Provider business mailing address

209 HIGHWAY PARK PLAZA
COVINGTON LA
70433
US

V. Phone/Fax

Practice location:
  • Phone: 985-892-6291
  • Fax: 985-892-8077
Mailing address:
  • Phone: 985-892-6291
  • Fax: 985-892-8077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMD.05634R
License Number StateLA

VIII. Authorized Official

Name: DR. SRINIVAS S GANJI
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 985-892-6291