Healthcare Provider Details

I. General information

NPI: 1881865392
Provider Name (Legal Business Name): SRINIVAS K. GANGINENI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2008
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

353 FAIRMONT BLVD
RAPID CITY SD
57701-7375
US

IV. Provider business mailing address

353 FAIRMONT BLVD
RAPID CITY SD
57701-7375
US

V. Phone/Fax

Practice location:
  • Phone: 605-755-1000
  • Fax: 605-755-8826
Mailing address:
  • Phone: 605-755-1000
  • Fax: 605-755-8826

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number50659
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number52222
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: