Provider Demographics
NPI:1205026879
Name:SRINIVASAN, SRIRAM (PT)
Entity Type:Individual
Prefix:
First Name:SRIRAM
Middle Name:
Last Name:SRINIVASAN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43154 DEQUINDRE RD
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48314-1723
Mailing Address - Country:US
Mailing Address - Phone:586-991-0430
Mailing Address - Fax:586-991-0435
Practice Address - Street 1:43154 DEQUINDRE RD
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48314-1723
Practice Address - Country:US
Practice Address - Phone:586-991-0430
Practice Address - Fax:586-991-0435
Is Sole Proprietor?:No
Enumeration Date:2007-07-30
Last Update Date:2012-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501005297225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI650E016550OtherBCBSM
MI650E016550OtherBCBSM