Provider Demographics
NPI:1790781938
Name:SRIRAM, INDRA (MD)
Entity Type:Individual
Prefix:DR
First Name:INDRA
Middle Name:
Last Name:SRIRAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:INDRAMBIKAI
Other - Middle Name:
Other - Last Name:SRIRAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:168 CAROLINA RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29229-7396
Mailing Address - Country:US
Mailing Address - Phone:260-602-4645
Mailing Address - Fax:
Practice Address - Street 1:168 CAROLINA RIDGE DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29229-7396
Practice Address - Country:US
Practice Address - Phone:260-602-4645
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2014-07-10
Deactivation Date:2006-03-15
Deactivation Code:
Reactivation Date:2006-03-28
Provider Licenses
StateLicense IDTaxonomies
IN01040404207RA0000X, 207RG0300X
SCMMD.36130 MD207RA0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0000XAllopathic & Osteopathic PhysiciansInternal MedicineAdolescent Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100439910Medicaid
INF38172Medicare UPIN
IN100439910Medicaid