Healthcare Provider Details

I. General information

NPI: 1346502697
Provider Name (Legal Business Name): SHRAVAN KOORAGAYALU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2012
Last Update Date: 11/27/2023
Certification Date: 10/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12502 WILLOWBROOK RD STE 280
CUMBERLAND MD
21502-6494
US

IV. Provider business mailing address

PO BOX 1671
CUMBERLAND MD
21501-1671
US

V. Phone/Fax

Practice location:
  • Phone: 240-964-8750
  • Fax: 240-964-8699
Mailing address:
  • Phone: 240-964-8342
  • Fax: 240-964-8337

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 TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberD90372
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number00292848
License Number StateNY
# 4
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberD90372
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: