Healthcare Provider Details

I. General information

NPI: 1871531947
Provider Name (Legal Business Name): SUJATHA KANNAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 05/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 ORLEANS ST BLOOMBERG CC 6321
BALTIMORE MD
21287-0010
US

IV. Provider business mailing address

PO BOX 64382
BALTIMORE MD
21264-4382
US

V. Phone/Fax

Practice location:
  • Phone: 410-955-6412
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301072890
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License NumberD72754
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: