Healthcare Provider Details

I. General information

NPI: 1306809298
Provider Name (Legal Business Name): SUBRAMANIAN SRINIVAS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/11/2006
Last Update Date: 10/22/2021
Certification Date: 10/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5601 LOCH RAVEN BLVD RUSSELL MORGAN BLDG., 3RD FLOOR
BALTIMORE MD
21239-2905
US

IV. Provider business mailing address

100 WALTER WARD BLVD STE 100
ABINGDON MD
21009-1283
US

V. Phone/Fax

Practice location:
  • Phone: 410-464-5600
  • Fax:
Mailing address:
  • Phone: 443-347-4700
  • Fax: 443-643-4707

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberD22652
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: