Provider Demographics
NPI:1659688224
Name:BOMMIREDDIPALLI, SRINIVAS S (MD)
Entity Type:Individual
Prefix:DR
First Name:SRINIVAS
Middle Name:S
Last Name:BOMMIREDDIPALLI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:SESHA
Other - Middle Name:SRINIVAS
Other - Last Name:BOMMIREDDIPALLI SATYA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:138 CATLIN AVE
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:14701-4719
Mailing Address - Country:US
Mailing Address - Phone:301-221-0034
Mailing Address - Fax:
Practice Address - Street 1:207 FOOTE AVE
Practice Address - Street 2:WCA HOSPITAL
Practice Address - City:JAMESTOWN
Practice Address - State:NY
Practice Address - Zip Code:14701
Practice Address - Country:US
Practice Address - Phone:301-618-3754
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-02
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY272799207R00000X
MD390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY272799OtherLICENSE
NY03841949Medicaid