Provider Demographics
NPI:1295396026
Name:AMILINENI, THARA SARASWATHI
Entity Type:Individual
Prefix:
First Name:THARA
Middle Name:SARASWATHI
Last Name:AMILINENI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 S FRONT ST
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17104-1619
Mailing Address - Country:US
Mailing Address - Phone:717-231-8323
Mailing Address - Fax:
Practice Address - Street 1:205 SOUTH FRONT STREET
Practice Address - Street 2:BRADY 3
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17104
Practice Address - Country:US
Practice Address - Phone:717-231-8775
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-24
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT219183207P00000X, 390200000X
PAMD478854207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA2I7958OtherMEDICARE
PA103698702Medicaid