Provider Demographics
NPI:1093029282
Name:SRINIVAS, PRIYANKA (MD)
Entity Type:Individual
Prefix:
First Name:PRIYANKA
Middle Name:
Last Name:SRINIVAS
Suffix:
Gender:F
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:PO BOX 1325
Mailing Address - Street 2:
Mailing Address - City:CORBIN
Mailing Address - State:KY
Mailing Address - Zip Code:40702-1325
Mailing Address - Country:US
Mailing Address - Phone:606-526-8131
Mailing Address - Fax:
Practice Address - Street 1:2 TRILLIUM WAY STE 306
Practice Address - Street 2:
Practice Address - City:CORBIN
Practice Address - State:KY
Practice Address - Zip Code:40701
Practice Address - Country:US
Practice Address - Phone:606-526-4070
Practice Address - Fax:606-526-4072
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-30
Last Update Date:2018-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301106258207R00000X, 208M00000X
TXBP10036943207R00000X
NE27438208M00000X
KYTP736208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine