Provider Demographics
NPI:1720184849
Name:RAMANUJA, SRINIVASAN (MD)
Entity Type:Individual
Prefix:DR
First Name:SRINIVASAN
Middle Name:
Last Name:RAMANUJA
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:PO BOX 8674
Mailing Address - Street 2:1230 E MAIN ST MANKATO CLINIC LTD
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001
Mailing Address - Country:US
Mailing Address - Phone:507-625-1811
Mailing Address - Fax:
Practice Address - Street 1:1421 PREMIER DR
Practice Address - Street 2:MANKATO CLINIC WICKERSHAM
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001
Practice Address - Country:US
Practice Address - Phone:507-625-1811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA88016207K00000X
MN49842207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNHP83054OtherHEALTH PARTNERS
MN168109OtherUCARE
MN236D3RAOtherBCBS
MN854903000Medicaid
MNNA2951051979OtherPREFERRED ONE
MN1720184849OtherAMERICA'S PPO
MNNA2951051979OtherPREFERRED ONE