Healthcare Provider Details

I. General information

NPI: 1235750316
Provider Name (Legal Business Name): SRI SAI RAJ,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2020
Last Update Date: 04/30/2020
Certification Date: 04/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7600 AUTUMN PARK WAY
MECHANICSVILLE VA
23116-3868
US

IV. Provider business mailing address

PO BOX 31494
HENRICO VA
23294-1494
US

V. Phone/Fax

Practice location:
  • Phone: 804-730-0009
  • Fax:
Mailing address:
  • Phone: 804-282-9133
  • Fax: 804-282-9135

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: PADMALATHA DHARANIKOTA
Title or Position: PRESIDENT
Credential: MD
Phone: 687-492-9804