Basic Information
| Provider Information | |||||||||
| NPI: | 1225084155 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SRINIVASAN | ||||||||
| FirstName: | PATTANAM | ||||||||
| MiddleName: | DORAI | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 110 N MUIRFIELD CIR | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460528182 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7653193522 | ||||||||
| FaxNumber: | 7653193522 | ||||||||
| Practice Location | |||||||||
| Address1: | 1831 N BELCHER RD STE E1 | ||||||||
| Address2: | |||||||||
| City: | CLEARWATER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337651442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7653193522 | ||||||||
| FaxNumber: | 7654506161 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2006 | ||||||||
| LastUpdateDate: | 05/18/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | 01056628A | IN | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 208VP0014X | 01056628A | IN | N | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine | 208VP0014X | ME124951 | FL | Y | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200434770 | 05 | IN | MEDICAID |