Basic Information
| Provider Information | |||||||||
| NPI: | 1023226081 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SIVAKUMARAN | ||||||||
| FirstName: | PRAVEEN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1700 TREE LN STE 490 | ||||||||
| Address2: | |||||||||
| City: | SNELLVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300786756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709792828 | ||||||||
| FaxNumber: | 7709793139 | ||||||||
| Practice Location | |||||||||
| Address1: | 631 PROFESSIONAL DR STE 450 | ||||||||
| Address2: | |||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300463370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709638030 | ||||||||
| FaxNumber: | 7703399577 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2007 | ||||||||
| LastUpdateDate: | 03/10/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | 073655 | GA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 003159182B | 05 | GA | MEDICAID | 2021831397 | 01 | GA | PTAN | OTHER |