Provider Demographics
NPI:1649244781
Name:BANURU, SRIDHAR (MD)
Entity Type:Individual
Prefix:
First Name:SRIDHAR
Middle Name:
Last Name:BANURU
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 1:4015 GATEWAY BLVD
Mailing Address - Street 2:SUITE 2120
Mailing Address - City:NEWBURGH
Mailing Address - State:IN
Mailing Address - Zip Code:47630-8925
Mailing Address - Country:US
Mailing Address - Phone:812-842-0907
Mailing Address - Fax:812-464-4485
Practice Address - Street 1:1138 N ELM ST
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:KY
Practice Address - Zip Code:42420
Practice Address - Country:US
Practice Address - Phone:270-827-8811
Practice Address - Fax:270-827-1221
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01055614A207RC0000X, 207RI0011X
KY39180207RC0000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64107493Medicaid
IN200519660Medicaid
KY64107493Medicaid
IN532500EEEMedicare PIN
KY178910LMedicare PIN
I31095Medicare UPIN