Provider Demographics
NPI:1538314166
Name:SRINIVASAN, SUDHA (MD)
Entity Type:Individual
Prefix:
First Name:SUDHA
Middle Name:
Last Name:SRINIVASAN
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 1:25 N WINFIELD RD
Mailing Address - Street 2:
Mailing Address - City:WINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60190
Mailing Address - Country:US
Mailing Address - Phone:630-933-4700
Mailing Address - Fax:630-933-4721
Practice Address - Street 1:25 N WINFIELD RD
Practice Address - Street 2:
Practice Address - City:WINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60190
Practice Address - Country:US
Practice Address - Phone:630-933-4700
Practice Address - Fax:630-933-4721
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-24
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036126561207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036126561Medicaid
ILCE8854OtherMEDICARE RAILROAD PTAN (GROUP)
206147077OtherMEDICARE PTAN (INDIVIDUAL)
ILP00959405OtherMEDICARE RAILROAD PTAN (INDIVIDUAL)
IL206147OtherMEDICARE PTAN (GROUP)