Provider Demographics
NPI:1285665067
Name:SREEDHARAN, SURESH (MD)
Entity Type:Individual
Prefix:
First Name:SURESH
Middle Name:
Last Name:SREEDHARAN
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 1:219 BROOKS AVENUE NORTH
Mailing Address - Street 2:
Mailing Address - City:THIEF RIVER FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56701
Mailing Address - Country:US
Mailing Address - Phone:218-681-4673
Mailing Address - Fax:
Practice Address - Street 1:219 BROOKS AVENUE NORTH
Practice Address - Street 2:
Practice Address - City:THIEF RIVER FALLS
Practice Address - State:MN
Practice Address - Zip Code:56701
Practice Address - Country:US
Practice Address - Phone:218-681-4673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2015-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN47461208000000X
WI61310-20208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1285665067Medicaid
WI1285665067Medicaid
MN25328OtherNDBS #
MN370002985Medicare ID - Type UnspecifiedMN MEDICARE #
MN1203186OtherMEDICA #
MN40202OtherLHS/BANNERHEALTH #
MN953S4SROtherMNBS #
MN370003437Medicare PIN
MNHP49700OtherHEALTHPARTNERS #
MNI26066Medicare UPIN
MN647668600Medicaid
MN137078OtherUCARE #
MNDA9021043949OtherPREFERRED ONE #