Provider Demographics
NPI:1588643639
Name:PURIGHALLA, SRINIVASAN S (MD)
Entity Type:Individual
Prefix:
First Name:SRINIVASAN
Middle Name:S
Last Name:PURIGHALLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:616 35TH AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-6158
Mailing Address - Country:US
Mailing Address - Phone:309-517-3775
Mailing Address - Fax:309-517-3625
Practice Address - Street 1:616 35TH AVE STE 1
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-6158
Practice Address - Country:US
Practice Address - Phone:309-517-3775
Practice Address - Fax:309-517-3625
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-16
Last Update Date:2015-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036111101207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL5505740001OtherDMER
ILP00136579OtherMEDICARE RAILROAD
IN036111101Medicaid
ILP00136579OtherMEDICARE RAILROAD
ILK06698Medicare PIN