1639190705 NPI number — SRINIVAS PAVULURI, MD, PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639190705 NPI number — SRINIVAS PAVULURI, MD, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SRINIVAS PAVULURI, MD, PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1639190705
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/19/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 71
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOLMDEL
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07733-0071
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
732-264-4301
Provider Business Mailing Address Fax Number:
732-264-1102

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
668 N BEERS ST
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
HOLMDEL
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07733-1526
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
732-264-4301
Provider Business Practice Location Address Fax Number:
732-264-1102
Provider Enumeration Date:
07/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PAVULURI
Authorized Official First Name:
SRINIVAS
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
732-264-4301

Provider Taxonomy Codes

  • Taxonomy code: 2084N0400X , with the licence number:  25MA07341500 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 056224U33 . This is a "MEDICARE PTAN#" identifier . This identifiers is of the category "OTHER".




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