Provider Demographics
NPI:1508882945
Name:MEDURI, SIVARAMA KRISHNA (MD)
Entity Type:Individual
Prefix:
First Name:SIVARAMA
Middle Name:KRISHNA
Last Name:MEDURI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1020 CHATTANOOGA AVE
Mailing Address - Street 2:STE A&B
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720
Mailing Address - Country:US
Mailing Address - Phone:706-226-1300
Mailing Address - Fax:706-275-6478
Practice Address - Street 1:1020 CHATTANOOGA AVE
Practice Address - Street 2:STE A&B
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720
Practice Address - Country:US
Practice Address - Phone:706-226-1300
Practice Address - Fax:706-275-6478
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA020055207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA85000113GMedicaid
GA85000113GMedicaid