Provider Demographics
NPI:1629114517
Name:SRIRAMA, KIRAN (MD)
Entity Type:Individual
Prefix:
First Name:KIRAN
Middle Name:
Last Name:SRIRAMA
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 1:1340 S DAMEN AVE STE 400
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-1169
Mailing Address - Country:US
Mailing Address - Phone:773-292-4800
Mailing Address - Fax:312-564-4059
Practice Address - Street 1:1340 S DAMEN AVE STE 400
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-1169
Practice Address - Country:US
Practice Address - Phone:773-292-4800
Practice Address - Fax:312-564-4059
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-087528207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-087528OtherLIC PHY