Provider Demographics
NPI:1619126265
Name:SIVASUBRAMANIAN, SREEHARI
Entity Type:Individual
Prefix:
First Name:SREEHARI
Middle Name:
Last Name:SIVASUBRAMANIAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1960 28TH ST SE
Mailing Address - Street 2:SUITE B
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49508-7900
Mailing Address - Country:US
Mailing Address - Phone:616-475-9888
Mailing Address - Fax:616-475-9889
Practice Address - Street 1:1960 28TH ST SE
Practice Address - Street 2:SUITE B
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49508-7900
Practice Address - Country:US
Practice Address - Phone:616-475-9888
Practice Address - Fax:616-475-9889
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-18
Last Update Date:2008-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501012811225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist