Healthcare Provider Details

I. General information

NPI: 1790825487
Provider Name (Legal Business Name): SIRISH MADDALI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2007
Last Update Date: 01/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

244 WESTERN AVENUE
SOUTH PORTLAND ME
04106
US

IV. Provider business mailing address

244 WESTERN AVENUE
SOUTH PORTLAND ME
04106
US

V. Phone/Fax

Practice location:
  • Phone: 207-775-3446
  • Fax: 207-879-1646
Mailing address:
  • Phone: 207-775-3446
  • Fax: 207-879-1646

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberA90979
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: