Provider Demographics
NPI:1467489583
Name:PALLATH, SREYA (MD)
Entity Type:Individual
Prefix:
First Name:SREYA
Middle Name:
Last Name:PALLATH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4542 W 95TH ST
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-2627
Mailing Address - Country:US
Mailing Address - Phone:708-425-0522
Mailing Address - Fax:
Practice Address - Street 1:4542 W 95TH ST
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2627
Practice Address - Country:US
Practice Address - Phone:708-425-0522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036106563207R00000X
IL036-106563207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036106563Medicaid
ILI25978Medicare UPIN
IL211997Medicare ID - Type Unspecified