Provider Demographics
NPI:1063476661
Name:SHRIKANTHAN, MICHELE SORAYA (MD)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:SORAYA
Last Name:SHRIKANTHAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MICHELE
Other - Middle Name:SORAYA
Other - Last Name:MOHAMADI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:100 E LANCASTER AVE
Mailing Address - Street 2:MOB EAST, SUITE 467
Mailing Address - City:WYNNEWOOD
Mailing Address - State:PA
Mailing Address - Zip Code:19096-3450
Mailing Address - Country:US
Mailing Address - Phone:610-896-7424
Mailing Address - Fax:610-896-6171
Practice Address - Street 1:2901 JOLLY RD
Practice Address - Street 2:
Practice Address - City:PLYMOUTH MEETING
Practice Address - State:PA
Practice Address - Zip Code:19462-2324
Practice Address - Country:US
Practice Address - Phone:610-272-8221
Practice Address - Fax:610-272-8221
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD422605207RG0300X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
5N422Medicare ID - Type Unspecified
I47433Medicare UPIN