Provider Demographics
NPI:1770579922
Name:SRINIVASAN, KRISHNAN (MD)
Entity type:Individual
Prefix:DR
First Name:KRISHNAN
Middle Name:
Last Name:SRINIVASAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 W UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-3981
Mailing Address - Country:US
Mailing Address - Phone:217-366-1299
Mailing Address - Fax:
Practice Address - Street 1:101 W UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-3981
Practice Address - Country:US
Practice Address - Phone:217-366-1299
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-084652207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400112794OtherMEDICARE PTAN
IL036-084-652Medicaid
1770579922OtherNPI
1770579922OtherNPI
ILK03021Medicare ID - Type UnspecifiedMCHENRY COUNTY
ILF70788Medicare UPIN
ILK03019Medicare ID - Type UnspecifiedCOOK COUNTY
IL1144523994OtherGROUP NPI