MEDICARE: SRIDEVI GOWRAVARAM MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	53897	MN
2	208000000X	Pediatrics Physician	72556	GA

General Provider Information

NPI Number	:	1558305888
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SRIDEVI GOWRAVARAM MD

Provider Business Mailing Address
First Line	:	101 REGENCY PARK DR STE 140
Second Line	:
City	:	MCDONOUGH
State	:	GA
Zip	:	30253-7076
Country	:	US
Telephone Number	:	218-683-2698
Fax Number	:

Provider Business Practice Location Address
First Line	:	101 REGENCY PARK DR STE 140
Second Line	:
City	:	MCDONOUGH
State	:	GA
Zip	:	30253-7076
Country	:	US
Telephone Number	:	770-957-8626
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/16/2006
Last Update Date	:	03/09/2016

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