Provider Demographics
NPI:1598714990
Name:SRIDHARAN, MAILVAGANAM (MD)
Entity Type:Individual
Prefix:DR
First Name:MAILVAGANAM
Middle Name:
Last Name:SRIDHARAN
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 1:5943 STADIUM DR
Mailing Address - Street 2:STE 1
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-3016
Mailing Address - Country:US
Mailing Address - Phone:269-552-2836
Mailing Address - Fax:
Practice Address - Street 1:1521 GULL RD
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49048-1640
Practice Address - Country:US
Practice Address - Phone:269-226-5165
Practice Address - Fax:269-226-5166
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2016-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301078343207R00000X, 207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI382567464050OtherCOMMUNITY CHOICE MI
MI700F325300OtherBCN
MIP00261670OtherMETRAHEALTH RR
MIMS078343OtherBCBS OF MI
MI110223577OtherMETRAHEALTH RR
MI4316669Medicaid
MI382567464050OtherCOMMUNITY CHOICE MI
H39245Medicare UPIN
MIN98700004Medicare ID - Type Unspecified
MI110223577OtherMETRAHEALTH RR
MI4316669Medicaid