Provider Demographics
NPI:1669709796
Name:SEELAM, SRINIVASU (BPT)
Entity type:Individual
Prefix:MR
First Name:SRINIVASU
Middle Name:
Last Name:SEELAM
Suffix:
Gender:M
Credentials:BPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2375 CLUB MERIDIAN DR APT 4B
Mailing Address - Street 2:
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-4522
Mailing Address - Country:US
Mailing Address - Phone:215-760-9071
Mailing Address - Fax:
Practice Address - Street 1:2815 S PENNSYLVANIA AVE STE 4
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910-3496
Practice Address - Country:US
Practice Address - Phone:517-975-9900
Practice Address - Fax:517-975-9913
Is Sole Proprietor?:No
Enumeration Date:2009-11-10
Last Update Date:2018-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501014016225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1932142429Medicaid