Provider Demographics
NPI:1831175173
Name:EKANAYAKE, SURENDRANATH P (MD)
Entity type:Individual
Prefix:
First Name:SURENDRANATH
Middle Name:P
Last Name:EKANAYAKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 RAYLOC DR
Mailing Address - Street 2:
Mailing Address - City:HANCOCK
Mailing Address - State:MD
Mailing Address - Zip Code:21750-1518
Mailing Address - Country:US
Mailing Address - Phone:301-678-5187
Mailing Address - Fax:301-678-5797
Practice Address - Street 1:12502 WILLOWBROOK RD
Practice Address - Street 2:SUITE 550
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21502-6491
Practice Address - Country:US
Practice Address - Phone:301-723-3940
Practice Address - Fax:301-723-3941
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2017-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD54964207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810005772Medicaid
MD211849OtherMEDICARE FQHC
PA1007288800008Medicaid
MD482501200Medicaid
TX188838001Medicaid
TX8G7178OtherBCBS
MD211849OtherMEDICARE FQHC
H01551Medicare UPIN
TX188838001Medicaid