Provider Demographics
NPI:1124007265
Name:SRINIVASAN S PURIGHALLA
Entity Type:Organization
Organization Name:SRINIVASAN S PURIGHALLA
Other - Org Name:PURIGHALLA NEUROSCIENCE & SPINE INSTITUTE LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SRINIVASAN
Authorized Official - Middle Name:S
Authorized Official - Last Name:PURIGHALLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-517-3775
Mailing Address - Street 1:616 35TH AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-6158
Mailing Address - Country:US
Mailing Address - Phone:309-517-3775
Mailing Address - Fax:309-517-3625
Practice Address - Street 1:616 35TH AVE STE 1
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-6158
Practice Address - Country:US
Practice Address - Phone:309-517-3775
Practice Address - Fax:309-517-3625
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-16
Last Update Date:2015-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036111101207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILDC0079OtherMEDICARE RAILROAD
IL036111101Medicaid
ILDC0079OtherMEDICARE RAILROAD
IN209067Medicare ID - Type UnspecifiedGROUP PROVIDER NUMBER