1073847794 NPI number — DR. SOURENDRA RAUT MD FRCSC

Table of content: DR. SOURENDRA RAUT MD FRCSC (NPI 1073847794)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073847794 NPI number — DR. SOURENDRA RAUT MD FRCSC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RAUT
Provider First Name:
SOURENDRA
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD FRCSC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073847794
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/28/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1100 NORTHSIDE FORSYTH DRIVE
Provider Second Line Business Mailing Address:
SUITE 340
Provider Business Mailing Address City Name:
CUMMING
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30041
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-886-8111
Provider Business Mailing Address Fax Number:
770-205-8539

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1100 NORTHSIDE FORSYTH DRIVE
Provider Second Line Business Practice Location Address:
SUITE 340
Provider Business Practice Location Address City Name:
CUMMING
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30041
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-886-8111
Provider Business Practice Location Address Fax Number:
770-205-8539
Provider Enumeration Date:
09/28/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  065169 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207XX0004X , with the licence number: 065169 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 003100343A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003100434B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003100434C , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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