Provider Demographics
NPI:1356500631
Name:SUSHMA GORRELA FAMILY PRACTICE
Entity Type:Organization
Organization Name:SUSHMA GORRELA FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MANI
Authorized Official - Middle Name:KISHORE
Authorized Official - Last Name:SHARMA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-257-5977
Mailing Address - Street 1:18 MEADOWRIDGE PL
Mailing Address - Street 2:
Mailing Address - City:THE WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77381-6275
Mailing Address - Country:US
Mailing Address - Phone:281-257-5977
Mailing Address - Fax:281-257-5966
Practice Address - Street 1:18 MEADOWRIDGE PL
Practice Address - Street 2:
Practice Address - City:THE WOODLANDS
Practice Address - State:TX
Practice Address - Zip Code:77381-6275
Practice Address - Country:US
Practice Address - Phone:281-257-5977
Practice Address - Fax:281-257-5966
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUSHMA GORRELA FAMILY PRACTICE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-06-03
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL6740207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXH97569Medicare UPIN
TX00990VMedicare PIN