Provider Demographics
NPI:1427071380
Name:SARATH B GANGAVARAPU MD PC
Entity type:Organization
Organization Name:SARATH B GANGAVARAPU MD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL
Authorized Official - Prefix:
Authorized Official - First Name:SARATH
Authorized Official - Middle Name:B
Authorized Official - Last Name:GANGAVARAPU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:423-559-8989
Mailing Address - Street 1:PO BOX 4816
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37320
Mailing Address - Country:US
Mailing Address - Phone:423-559-8989
Mailing Address - Fax:423-559-8984
Practice Address - Street 1:2765 EXECUTIVE PARK DR NW
Practice Address - Street 2:STE 1
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37312
Practice Address - Country:US
Practice Address - Phone:423-559-8989
Practice Address - Fax:423-559-8984
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD00000163502084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3732603Medicaid
C36330Medicare UPIN
3732603Medicare ID - Type Unspecified