Provider Demographics
NPI:1164483871
Name:SIRUVELLA, SRIDEVI (MD)
Entity Type:Individual
Prefix:
First Name:SRIDEVI
Middle Name:
Last Name:SIRUVELLA
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 1:705 BREEDLOVE DR
Mailing Address - Street 2:SUITE 800
Mailing Address - City:MONROE
Mailing Address - State:GA
Mailing Address - Zip Code:30655-2090
Mailing Address - Country:US
Mailing Address - Phone:770-266-0567
Mailing Address - Fax:770-266-0507
Practice Address - Street 1:705 BREEDLOVE DR
Practice Address - Street 2:SUITE 800
Practice Address - City:MONROE
Practice Address - State:GA
Practice Address - Zip Code:30655-2090
Practice Address - Country:US
Practice Address - Phone:770-266-0567
Practice Address - Fax:770-266-0507
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA057019207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA245861061CMedicaid
GA08CBBWJMedicare PIN
GA245861061CMedicaid
GAP00380406Medicare PIN