Basic Information
| Provider Information | |||||||||
| NPI: | 1902153190 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GAUTAM SIRAM, MD, PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 5530 WISCONSIN AVE STE 1660 | ||||||||
| Address2: | |||||||||
| City: | CHEVY CHASE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208154322 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016579876 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5530 WISCONSIN AVE STE 1660 | ||||||||
| Address2: | |||||||||
| City: | CHEVY CHASE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208154322 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016579876 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2012 | ||||||||
| LastUpdateDate: | 08/07/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SIRAM | ||||||||
| AuthorizedOfficialFirstName: | GAUTAM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3017854559 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XS0114X | D0074565 | MD | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Adult Reconstructive Orthopaedic Surgery |
No ID Information.