Provider Demographics
NPI:1073847794
Name:RAUT, SOURENDRA (MD FRCSC)
Entity Type:Individual
Prefix:DR
First Name:SOURENDRA
Middle Name:
Last Name:RAUT
Suffix:
Gender:M
Credentials:MD FRCSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 NORTHSIDE FORSYTH DRIVE
Mailing Address - Street 2:SUITE 340
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041
Mailing Address - Country:US
Mailing Address - Phone:770-886-8111
Mailing Address - Fax:770-205-8539
Practice Address - Street 1:1100 NORTHSIDE FORSYTH DRIVE
Practice Address - Street 2:SUITE 340
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041
Practice Address - Country:US
Practice Address - Phone:770-886-8111
Practice Address - Fax:770-205-8539
Is Sole Proprietor?:No
Enumeration Date:2009-09-28
Last Update Date:2011-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA065169207X00000X, 207XX0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003100343AMedicaid
GA003100434BMedicaid
GA003100434CMedicaid
GA003100434CMedicaid