Provider Demographics
NPI:1003818923
Name:MAGANTI, BHAVAGAN S (MD)
Entity Type:Individual
Prefix:
First Name:BHAVAGAN
Middle Name:S
Last Name:MAGANTI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 GANNETT DR STE 200
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-3266
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:690 MINOT AVE STE 1
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:ME
Practice Address - Zip Code:04210-3922
Practice Address - Country:US
Practice Address - Phone:207-344-2220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2012-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME85406207L00000X
ME008618207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME297670099Medicaid
FL300803700OtherDOL ACS (FECA) W/C
FLP00009748OtherMEDICARE RAILROAD
FL29222OtherFL BCBS PROVIDER #
FL29222OtherFL BCBS PROVIDER #
MED79266Medicare UPIN
ME297670099Medicaid
ME01563101Medicare PIN