Provider Demographics
NPI:1538107610
Name:SURESH, SRINIVASAN (MD)
Entity Type:Individual
Prefix:
First Name:SRINIVASAN
Middle Name:
Last Name:SURESH
Suffix:
Gender:M
Credentials:MD
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1420 STEPHENSON HWY
Mailing Address - Street 2:SUITE 400-CREDENTIALING
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-1189
Mailing Address - Country:US
Mailing Address - Phone:248-581-5975
Mailing Address - Fax:248-581-5640
Practice Address - Street 1:CHILDRENS HOSPITAL MI EMERGENCY MED
Practice Address - Street 2:3901 BEAUBIEN ER DEPT - MAIN BUILDING
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201
Practice Address - Country:US
Practice Address - Phone:313-745-5260
Practice Address - Fax:313-993-7166
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2014-06-20
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Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301061925208000000X, 2080P0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M76490078Medicare PIN