Healthcare Provider Details

I. General information

NPI: 1699722009
Provider Name (Legal Business Name): PREMA SIVA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2006
Last Update Date: 04/04/2024
Certification Date: 04/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8871 GORMAN RD STE 300
LAUREL MD
20723-5877
US

IV. Provider business mailing address

8871 GORMAN RD STE 300
LAUREL MD
20723-5877
US

V. Phone/Fax

Practice location:
  • Phone: 410-498-3150
  • Fax: 410-601-8886
Mailing address:
  • Phone: 410-498-3150
  • Fax: 410-601-8886

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number186016
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberD66419
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: