Basic Information
| Provider Information | |||||||||
| NPI: | 1710327424 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SURAKANTI | ||||||||
| FirstName: | SHRAVANI | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4155 ESSEN LN | ||||||||
| Address2: | APT 135 | ||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708092150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7653665056 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8585 PICARDY AVE | ||||||||
| Address2: | SUITE 414 | ||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708093748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2257634764 | ||||||||
| FaxNumber: | 2257634549 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2013 | ||||||||
| LastUpdateDate: | 10/07/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD.303223 | LA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2426966 | 05 | LA | MEDICAID |