1538471008 NPI number — SRILATHA POLSANI MD

Table of content: SRILATHA POLSANI MD (NPI 1538471008)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538471008 NPI number — SRILATHA POLSANI MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POLSANI
Provider First Name:
SRILATHA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1538471008
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/04/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 820933
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19182-0933
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-926-9010
Provider Business Mailing Address Fax Number:
215-226-8285

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7600 CENTRAL AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19111-2442
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-728-2000
Provider Business Practice Location Address Fax Number:
215-214-4119
Provider Enumeration Date:
07/13/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  MD429883 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1007278000087 . This is a "TPI GROUP MEDICAID" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 597586 . This is a "TPI MEDICARE GROUP" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1024802750001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: CD4829 . This is a "TPI GROUP RAILROAD MEDICARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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