Provider Demographics
NPI:1467474726
Name:POONAM SRIVASTAVA MD PC
Entity type:Organization
Organization Name:POONAM SRIVASTAVA MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:NAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:SRIVASTAVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-374-8555
Mailing Address - Street 1:1575 N OLD TRAIL
Mailing Address - Street 2:
Mailing Address - City:SELINSGROVE
Mailing Address - State:PA
Mailing Address - Zip Code:17870-1575
Mailing Address - Country:US
Mailing Address - Phone:570-374-8555
Mailing Address - Fax:570-374-9933
Practice Address - Street 1:1575 N OLD TRAIL
Practice Address - Street 2:
Practice Address - City:SELINSGROVE
Practice Address - State:PA
Practice Address - Zip Code:17870-1575
Practice Address - Country:US
Practice Address - Phone:570-374-8555
Practice Address - Fax:570-374-9933
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-24
Last Update Date:2010-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA291U00000X
207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
No291U00000XLaboratoriesClinical Medical LaboratoryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007421000005Medicaid
PA1007421000009Medicaid
PA031076Medicare PIN
PA0822630001Medicare NSC