Basic Information
| Provider Information | |||||||||
| NPI: | 1003821844 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MADHUNAPANTULA | ||||||||
| FirstName: | SRIDHAR | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 200 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | GALAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 243332227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2762383566 | ||||||||
| FaxNumber: | 2762368780 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | GALAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 243332227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2762383566 | ||||||||
| FaxNumber: | 2762368780 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2006 | ||||||||
| LastUpdateDate: | 08/03/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 0101238020 | VA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | ME95109 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0101241090 | 05 | VA | MEDICAID |