Healthcare Provider Details

I. General information

NPI: 1508184102
Provider Name (Legal Business Name): SARATH B. GANGAVARAPU
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2010
Last Update Date: 05/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1008 HIGHWAY 28
JASPER TN
37347-3638
US

IV. Provider business mailing address

1008 HIGHWAY 28
JASPER TN
37347-3638
US

V. Phone/Fax

Practice location:
  • Phone: 423-837-3350
  • Fax: 423-837-9525
Mailing address:
  • Phone: 423-837-3350
  • Fax: 423-837-9525

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD16350
License Number StateTN

VIII. Authorized Official

Name: SARATH B GANGAVARAPU
Title or Position: M.D.
Credential: M.D.
Phone: 423-837-3350