Provider Demographics
NPI:1730126012
Name:SRINIVASAN, RAJAMMAL (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:RAJAMMAL
Middle Name:
Last Name:SRINIVASAN
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3800 HIGHLAND AVE, SUITE111
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515
Mailing Address - Country:US
Mailing Address - Phone:630-852-4850
Mailing Address - Fax:630-852-4860
Practice Address - Street 1:3800 HIGHLAND AVE, STE111
Practice Address - Street 2:
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515
Practice Address - Country:US
Practice Address - Phone:630-852-4850
Practice Address - Fax:630-852-4860
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-02
Last Update Date:2013-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036067525207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036067525Medicaid
IL02201519OtherBLUECROSS BLUESHIELD
IL036067525Medicaid
ILC38183Medicare UPIN