Provider Demographics
NPI:1164868485
Name:SRIDHAR, MALORIE LYN (MD)
Entity Type:Individual
Prefix:
First Name:MALORIE
Middle Name:LYN
Last Name:SRIDHAR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:24 FRANK LLOYD WRIGHT DR # J2000
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105-9484
Mailing Address - Country:US
Mailing Address - Phone:734-747-6766
Mailing Address - Fax:734-222-3100
Practice Address - Street 1:4940 W CLARK RD STE 100
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-0860
Practice Address - Country:US
Practice Address - Phone:734-971-1188
Practice Address - Fax:734-971-3658
Is Sole Proprietor?:No
Enumeration Date:2013-05-14
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101267008207Q00000X
NC2015-00635207Q00000X, 208M00000X
390200000X
MI4301508695207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program