Provider Demographics
NPI:1689931420
Name:SRINIVAS MEDICAL INC
Entity Type:Organization
Organization Name:SRINIVAS MEDICAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:SRINIVAS-PRASAD
Authorized Official - Middle Name:REDDY
Authorized Official - Last Name:JOLEPALEM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-888-4815
Mailing Address - Street 1:8721 CARRIAGE GREEN DRIVE
Mailing Address - Street 2:
Mailing Address - City:DARIEN
Mailing Address - State:IL
Mailing Address - Zip Code:60561-8468
Mailing Address - Country:US
Mailing Address - Phone:630-888-4815
Mailing Address - Fax:630-910-4020
Practice Address - Street 1:8721 CARRIAGE GREEN DRIVE
Practice Address - Street 2:
Practice Address - City:DARIEN
Practice Address - State:IL
Practice Address - Zip Code:60561-8468
Practice Address - Country:US
Practice Address - Phone:630-888-4815
Practice Address - Fax:630-910-4020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-18
Last Update Date:2013-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036084786207R00000X
WI32848-20207R00000X
IN01064406A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036084786Medicaid
ILF46755Medicare UPIN