Healthcare Provider Details

I. General information

NPI: 1841545233
Provider Name (Legal Business Name): RAM KISHORE R GURAJALA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2012
Last Update Date: 05/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23305 CHAGRIN BLVD 405S
BEACHWOOD OH
44122-5549
US

IV. Provider business mailing address

CHAGRIN BLVD
BEACHWOOD OH
44122-5549
US

V. Phone/Fax

Practice location:
  • Phone: 845-705-9209
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number57.020760
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number35.125706
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: