Healthcare Provider Details

I. General information

NPI: 1215291232
Provider Name (Legal Business Name): EELLAN SIVANESAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2012
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 N WOLFE ST
BALTIMORE MD
21287-0005
US

IV. Provider business mailing address

9910 FRANKLIN SQUARE DR STE 2110
BALTIMORE MD
21236-4902
US

V. Phone/Fax

Practice location:
  • Phone: 410-955-1822
  • Fax: 410-367-2047
Mailing address:
  • Phone: 410-933-6423
  • Fax: 410-933-1390

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number125061895
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberME126946
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125061895
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberD83568
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: