Healthcare Provider Details

I. General information

NPI: 1417958851
Provider Name (Legal Business Name): SURAPANENI P RAMANADHA RAO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 12/21/2020
Certification Date: 12/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

58 MAIN ST
BUCKSPORT ME
04416-4112
US

IV. Provider business mailing address

58 MAIN ST
BUCKSPORT ME
04416-4112
US

V. Phone/Fax

Practice location:
  • Phone: 207-469-6880
  • Fax: 207-469-3766
Mailing address:
  • Phone: 207-469-6880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberMD9356
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: