1659762631 NPI number — DEEPA SRIDHAR P.C

Table of content: (NPI 1659762631)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659762631 NPI number — DEEPA SRIDHAR P.C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DEEPA SRIDHAR P.C
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:
6
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:
1659762631
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/11/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
217 S BOLINGBROOK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOLINGBROOK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60440-2931
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-313-4918
Provider Business Mailing Address Fax Number:
630-626-4784

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
217 S BOLINGBROOK DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOLINGBROOK
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60440-2931
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-313-4918
Provider Business Practice Location Address Fax Number:
630-626-4784
Provider Enumeration Date:
02/11/2015

Additional Information

Authorized Official

Authorized Official Last Name:
SRIDHAR
Authorized Official First Name:
DEEPA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
630-313-4918

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  019026471 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 9178432 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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