Provider Demographics
NPI:1568687317
Name:T SRI MD A PROFESSIONAL CORP
Entity Type:Organization
Organization Name:T SRI MD A PROFESSIONAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THILLAIAMPALAM
Authorized Official - Middle Name:
Authorized Official - Last Name:SRIJAERAJAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-373-4809
Mailing Address - Street 1:44725 10TH ST W STE 230
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93534-3048
Mailing Address - Country:US
Mailing Address - Phone:661-948-1611
Mailing Address - Fax:661-945-5291
Practice Address - Street 1:9278 N LOOP BLVD
Practice Address - Street 2:
Practice Address - City:CALIFORNIA CITY
Practice Address - State:CA
Practice Address - Zip Code:93505-2236
Practice Address - Country:US
Practice Address - Phone:760-373-4809
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2010-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA33938173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0064520Medicaid
CAGR0064251Medicaid
CAGR0064520Medicaid
CAA84542Medicare UPIN
CAGR0064251Medicaid