Provider Demographics
NPI:1700891454
Name:PERUMANDLA, SIRISHA (MD)
Entity type:Individual
Prefix:
First Name:SIRISHA
Middle Name:
Last Name:PERUMANDLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4300 ALLEN RD
Mailing Address - Street 2:
Mailing Address - City:STOW
Mailing Address - State:OH
Mailing Address - Zip Code:44224-1032
Mailing Address - Country:US
Mailing Address - Phone:330-344-6505
Mailing Address - Fax:
Practice Address - Street 1:4300 ALLEN RD
Practice Address - Street 2:
Practice Address - City:STOW
Practice Address - State:OH
Practice Address - Zip Code:44224-1032
Practice Address - Country:US
Practice Address - Phone:330-344-6505
Practice Address - Fax:330-344-6431
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2025-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.152265207RH0003X
IA36765207RH0003X
KYTP947207RH0003X
KY44696207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1499426Medicaid
1700891454OtherTRICARE
IAZZ207RH00033XMedicaid
25031OtherBLUE CROSS/BLUE SHIELD
KY50034241OtherPASSPORT HEALTH PLAN/PASSPORT ADVANTAGE
1700891454OtherTRICARE
KY87090OtherCOVENTRYCARES OF KENTUCKY
IAZZ207RH00033XMedicaid
KY170891454OtherHUMANA
IA25208OtherWELLMARK BCBS
IAI8485Medicare PIN
KY50034241OtherPASSPORT HEALTH PLAN/PASSPORT ADVANTAGE
IA25208OtherWELLMARK BCBS
H77119Medicare UPIN