Basic Information
| Provider Information | |||||||||
| NPI: | 1194045013 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MIRYANAM | ||||||||
| FirstName: | SRINIVAS | ||||||||
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| NamePrefix: | MR. | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2320 N VERMILION ST | ||||||||
| Address2: | APT 322 | ||||||||
| City: | DANVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618321739 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2053811997 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1600 LIBERTY ST | ||||||||
| Address2: | |||||||||
| City: | COVINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479321715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7657934818 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2010 | ||||||||
| LastUpdateDate: | 06/02/2010 | ||||||||
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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 | 225100000X | 05010247A | IN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 5501015050 | MI | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.