Provider Demographics
NPI:1508067786
Name:SHRIVASTAVA, PRITIKA (MD)
Entity Type:Individual
Prefix:
First Name:PRITIKA
Middle Name:
Last Name:SHRIVASTAVA
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 1:130 TOWN CENTER DR STE 203
Mailing Address - Street 2:BEAUMONT PROVIDER ENROLLMENT
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-1744
Mailing Address - Country:US
Mailing Address - Phone:248-585-8216
Mailing Address - Fax:
Practice Address - Street 1:3535 W 13 MILE RD STE 644
Practice Address - Street 2:BEAUMONT MULTI-ORGAN TRANSPLANT CLINIC
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-6770
Practice Address - Country:US
Practice Address - Phone:800-253-5592
Practice Address - Fax:248-551-2125
Is Sole Proprietor?:No
Enumeration Date:2007-05-29
Last Update Date:2015-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD434606207R00000X
MI4301101565207R00000X, 207RN0300X
PAMT190509207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA121910OtherGEISINGER HEALTH PLAN
PA1577253OtherGATEWAY-WMG
PA257944OtherUNISON-WMG
PA20080686OtherAMERIHEALTH MERCY-WMG
MI700F349850OtherBCBSM
PA2079421OtherHIGHMARK BLUE SHIELD
PA226021OtherJOHNS HOPKINS
MD945883OtherCAREFIRST MD BCBS
PA9815250OtherAETNA
PA102226350Medicaid
MI1811044878Medicaid
PA50081952OtherCAPITAL BLUE CROSS-WMG
MI0F34985Medicare PIN
PA2079421OtherHIGHMARK BLUE SHIELD