Healthcare Provider Details

I. General information

NPI: 1710366893
Provider Name (Legal Business Name): SAI KRISHNA SURAPA RAJU M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2015
Last Update Date: 11/25/2024
Certification Date: 11/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 BRAMHALL ST
PORTLAND ME
04102-3134
US

IV. Provider business mailing address

22 BRAMHALL ST
PORTLAND ME
04102-3134
US

V. Phone/Fax

Practice location:
  • Phone: 207-662-2273
  • Fax:
Mailing address:
  • Phone: 207-662-2273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License NumberS7149
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License NumberMD28644
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: