Basic Information
| Provider Information | |||||||||
| NPI: | 1376562231 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SRIDHARAN | ||||||||
| FirstName: | MARANDAPALLI | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1348 WALTON WAY | ||||||||
| Address2: | SUITE 5100 | ||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309015104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067248611 | ||||||||
| FaxNumber: | 7067246202 | ||||||||
| Practice Location | |||||||||
| Address1: | 1348 WALTON WAY | ||||||||
| Address2: | SUITE 5100 | ||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309015104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067248611 | ||||||||
| FaxNumber: | 7067246202 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 10/22/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 026392 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 198050 | 01 | GA | BCBS | OTHER | G26392 | 05 | SC | MEDICAID |