Provider Demographics
NPI:1497786123
Name:BOLISETTI, SREEDEVI (MD)
Entity Type:Individual
Prefix:
First Name:SREEDEVI
Middle Name:
Last Name:BOLISETTI
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 1:435 HURFFVILLE CROSS KEYS RD
Mailing Address - Street 2:
Mailing Address - City:TURNERSVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08012-2453
Mailing Address - Country:US
Mailing Address - Phone:856-566-6845
Mailing Address - Fax:856-566-6906
Practice Address - Street 1:435 HURFFVILLE CROSS KEYS RD
Practice Address - Street 2:
Practice Address - City:TURNERSVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08012-2453
Practice Address - Country:US
Practice Address - Phone:856-566-6845
Practice Address - Fax:856-566-6906
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07794800207R00000X, 208M00000X
PAMD425310207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0067156Medicaid
PA006715600Medicaid
NJP00813729OtherRAILROAD MEDICARE
PAP00703988Medicare PIN
NJ089262AEDMedicare PIN
NJI26793Medicare UPIN
PA120908JTQMedicare PIN