Healthcare Provider Details

I. General information

NPI: 1336450253
Provider Name (Legal Business Name): SHANNAROSE GUMA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHANNAROSE NIGRELLI M.D.

II. Dates (important events)

Enumeration Date: 06/25/2010
Last Update Date: 04/23/2025
Certification Date: 04/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3290 N RIDGE RD STE 220
ELLICOTT CITY MD
21043-3657
US

IV. Provider business mailing address

3290 N RIDGE RD STE 220
ELLICOTT CITY MD
21043-3657
US

V. Phone/Fax

Practice location:
  • Phone: 410-801-2273
  • Fax: 410-385-9319
Mailing address:
  • Phone: 410-801-2273
  • Fax: 410-385-9319

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberD0074300
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code2083B0002X
TaxonomyObesity Medicine (Preventive Medicine) Physician
License Number89993268
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: