Provider Demographics
NPI:1740411925
Name:SRIKANTH MAHAVADI
Entity type:Organization
Organization Name:SRIKANTH MAHAVADI
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SRIKANTH
Authorized Official - Middle Name:
Authorized Official - Last Name:MAHAVADI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-829-8999
Mailing Address - Street 1:PO BOX 357
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE FORGE
Mailing Address - State:VA
Mailing Address - Zip Code:23140-0357
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9050 POCAHONTAS TRAIL
Practice Address - Street 2:SUITE F
Practice Address - City:PROVIDENCE FORGE
Practice Address - State:VA
Practice Address - Zip Code:23140
Practice Address - Country:US
Practice Address - Phone:804-966-8350
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-05
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA009201429Medicaid
VA480000649Medicare PIN
VA1740411925Medicare NSC
VA4895310001Medicare NSC