Provider Demographics
NPI:1083689566
Name:SAMUDRALA, SREEDHAR (MD)
Entity Type:Individual
Prefix:DR
First Name:SREEDHAR
Middle Name:
Last Name:SAMUDRALA
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 1:1195 OLD HICKORY BLVD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-4239
Mailing Address - Country:US
Mailing Address - Phone:615-373-2000
Mailing Address - Fax:615-523-2900
Practice Address - Street 1:1195 OLD HICKORY BLVD
Practice Address - Street 2:SUITE 103
Practice Address - City:BRENTWOOD
Practice Address - State:TN
Practice Address - Zip Code:37027-4239
Practice Address - Country:US
Practice Address - Phone:615-373-2000
Practice Address - Fax:615-891-5001
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-20
Last Update Date:2016-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN36148207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3377514Medicaid
TN3377514Medicaid
TNH62107Medicare UPIN