Provider Demographics
NPI:1760662951
Name:SIRISHA KONERU, M.D, P.C.
Entity Type:Organization
Organization Name:SIRISHA KONERU, M.D, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SIRISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:KONERU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-888-8410
Mailing Address - Street 1:1762 WYNGATE DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48098-6545
Mailing Address - Country:US
Mailing Address - Phone:248-888-8410
Mailing Address - Fax:
Practice Address - Street 1:43171 DALCOMA DR
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-6307
Practice Address - Country:US
Practice Address - Phone:586-263-9772
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-06
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301079920207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty