Provider Demographics
NPI:1639453954
Name:SURAPANENI RAMANADHARAO MDPA
Entity Type:Organization
Organization Name:SURAPANENI RAMANADHARAO MDPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SURAPANENI
Authorized Official - Middle Name:P
Authorized Official - Last Name:RAMANADHARAO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:207-942-3878
Mailing Address - Street 1:PO BOX 8117
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04402-8117
Mailing Address - Country:US
Mailing Address - Phone:207-942-3878
Mailing Address - Fax:207-990-2803
Practice Address - Street 1:358 BROADWAY
Practice Address - Street 2:SUITE 207
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-3929
Practice Address - Country:US
Practice Address - Phone:207-942-3878
Practice Address - Fax:207-990-2803
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-05
Last Update Date:2011-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME9356208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME112410000Medicaid
MED03646Medicare UPIN