Provider Demographics
NPI:1306904438
Name:SREEROOPSEN M.D. LLC
Entity type:Organization
Organization Name:SREEROOPSEN M.D. LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:HOLCOMBE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-856-6973
Mailing Address - Street 1:77 W GIBSON ST
Mailing Address - Street 2:
Mailing Address - City:HARTWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30643-1845
Mailing Address - Country:US
Mailing Address - Phone:706-856-6973
Mailing Address - Fax:706-856-6976
Practice Address - Street 1:77 W GIBSON ST
Practice Address - Street 2:
Practice Address - City:HARTWELL
Practice Address - State:GA
Practice Address - Zip Code:30643-1845
Practice Address - Country:US
Practice Address - Phone:706-856-6973
Practice Address - Fax:706-856-6976
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2010-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP4369Medicare ID - Type Unspecified