Provider Demographics
NPI:1619948585
Name:KOLLI, SRINIVAS (MD INC)
Entity Type:Individual
Prefix:DR
First Name:SRINIVAS
Middle Name:
Last Name:KOLLI
Suffix:
Gender:M
Credentials:MD INC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 EAST MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:OH
Mailing Address - Zip Code:43130-3478
Mailing Address - Country:US
Mailing Address - Phone:740-687-9182
Mailing Address - Fax:740-687-0278
Practice Address - Street 1:1500 E MAIN ST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:OH
Practice Address - Zip Code:43130-3478
Practice Address - Country:US
Practice Address - Phone:740-687-9182
Practice Address - Fax:740-687-0278
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-30
Last Update Date:2010-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35068262K174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0169866Medicaid
OH4031191Medicare PIN