Provider Demographics
NPI:1902194897
Name:S K GANGULI MD PC
Entity Type:Organization
Organization Name:S K GANGULI MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MANJU
Authorized Official - Middle Name:
Authorized Official - Last Name:GANGULI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-761-5331
Mailing Address - Street 1:6005 PARK AVE
Mailing Address - Street 2:SUITE 308
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-5202
Mailing Address - Country:US
Mailing Address - Phone:901-761-5331
Mailing Address - Fax:
Practice Address - Street 1:6005 PARK AVE
Practice Address - Street 2:SUITE 308
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-5202
Practice Address - Country:US
Practice Address - Phone:901-761-5331
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-13
Last Update Date:2011-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD009353208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3170595Medicare PIN
TN3008317Medicare PIN