Provider Demographics
NPI:1427223346
Name:SRIRAM, CHENNI S (MD)
Entity Type:Individual
Prefix:
First Name:CHENNI
Middle Name:S
Last Name:SRIRAM
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 1:4201 ST. ANTOINE - UHC 5D MAILBOX 226
Mailing Address - Street 2:UNIVERSITY PEDIATRICIANS
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2153
Mailing Address - Country:US
Mailing Address - Phone:313-745-4405
Mailing Address - Fax:313-966-0665
Practice Address - Street 1:3901 BEAUBIEN - 4TH FL
Practice Address - Street 2:CHILDRENS HOSPITAL OF MI
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201
Practice Address - Country:US
Practice Address - Phone:313-745-5484
Practice Address - Fax:313-966-2423
Is Sole Proprietor?:No
Enumeration Date:2008-04-23
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD449353208000000X
OH57012940208000000X
MN104900208000000X
MN53481208000000X
MI570129402080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102844225Medicaid
PA102844225Medicaid