Provider Demographics
NPI:1780674226
Name:JAYARAM, SHRUTHI N (MD)
Entity Type:Individual
Prefix:
First Name:SHRUTHI
Middle Name:N
Last Name:JAYARAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SHRUTHI
Other - Middle Name:N
Other - Last Name:SRIKANTHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 650782
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75265-0782
Mailing Address - Country:US
Mailing Address - Phone:610-789-8070
Mailing Address - Fax:610-789-9937
Practice Address - Street 1:2010 OLD WEST CHESTER PIKE
Practice Address - Street 2:SUITE 330
Practice Address - City:HAVERTOWN
Practice Address - State:PA
Practice Address - Zip Code:19083-2712
Practice Address - Country:US
Practice Address - Phone:610-789-8070
Practice Address - Fax:610-789-9937
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2008-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD420440207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
11879715OtherCAQH
PA001915811Medicaid
2117899000OtherKHPE
PA001915811Medicaid