Provider Demographics
NPI:1114024908
Name:KRISHNASAMY, SRIRAM (MD)
Entity Type:Individual
Prefix:DR
First Name:SRIRAM
Middle Name:
Last Name:KRISHNASAMY
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:PO BOX 30805
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37040-0014
Mailing Address - Country:US
Mailing Address - Phone:931-542-2647
Mailing Address - Fax:931-542-2648
Practice Address - Street 1:298 CLEAR SKY CT
Practice Address - Street 2:SUITE B
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-5685
Practice Address - Country:US
Practice Address - Phone:931-542-2647
Practice Address - Fax:931-542-2648
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN34189207R00000X, 207RC0200X, 207RP1001X, 207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN38521912Medicaid
TN6013297OtherHEALTHSPRING
TN4219903OtherBCBS
TN7884977OtherAETNA
TN1508276Medicaid
TN4219903OtherBCBS
TN6013297OtherHEALTHSPRING
TN1508276Medicaid