Healthcare Provider Details

I. General information

NPI: 1952540635
Provider Name (Legal Business Name): SKANUMURU, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2009
Last Update Date: 02/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1406 CRAIN HWY S SUITE 108
GLEN BURNIE MD
21061-4058
US

IV. Provider business mailing address

5354 AMBROSIA DR
ELLICOTT CITY MD
21043-6862
US

V. Phone/Fax

Practice location:
  • Phone: 410-760-0098
  • Fax: 410-761-9131
Mailing address:
  • Phone: 410-336-0124
  • Fax: 410-744-6755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License NumberD0064539
License Number StateMD

VIII. Authorized Official

Name: DR. SRILATHA KANUMURU
Title or Position: OWNER
Credential: M.D.
Phone: 410-719-0020