Healthcare Provider Details

I. General information

NPI: 1669695946
Provider Name (Legal Business Name): RAJAGOPAL SRINIVASAN M.D., PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 12/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

981150 NEBRASKA MEDICAL CTR SECTION OF EMERGENCY MEDICINE ACADEMIC OFFICES
OMAHA NE
68198-1150
US

IV. Provider business mailing address

110 S PACA ST DEPARTMENT OF EMERGENCY MEDICINE 6TH FLOOR SUITE 200
BALTIMORE MD
21201-1642
US

V. Phone/Fax

Practice location:
  • Phone: 404-559-6802
  • Fax: 402-559-9659
Mailing address:
  • Phone: 410-328-8025
  • Fax: 410-328-8028

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number4977
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: