Provider Demographics
NPI:1770521510
Name:SRIVASTAVA, AMIT K (MD)
Entity type:Individual
Prefix:DR
First Name:AMIT
Middle Name:K
Last Name:SRIVASTAVA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3722 HARLEM AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:RIVERSIDE
Mailing Address - State:IL
Mailing Address - Zip Code:60546-2312
Mailing Address - Country:US
Mailing Address - Phone:708-783-7000
Mailing Address - Fax:708-783-7008
Practice Address - Street 1:3722 HARLEM AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:RIVERSIDE
Practice Address - State:IL
Practice Address - Zip Code:60546-2312
Practice Address - Country:US
Practice Address - Phone:708-783-7000
Practice Address - Fax:708-783-7008
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036071488207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1622295OtherBCBS #
IL036071488Medicaid
ILL68211Medicare ID - Type Unspecified
IL036071488Medicaid