Healthcare Provider Details

I. General information

NPI: 1144706979
Provider Name (Legal Business Name): SREELAKSHMI KOORAGAYALU MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2018
Last Update Date: 05/19/2022
Certification Date: 05/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12500 WILLOWBROOK RD
CUMBERLAND MD
21502-6393
US

IV. Provider business mailing address

16902 MOUNTAIN CLUB AVE
RAWLINGS MD
21557-1041
US

V. Phone/Fax

Practice location:
  • Phone: 240-964-1200
  • Fax:
Mailing address:
  • Phone: 929-313-4430
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberD0090518
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number22596
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: