Basic Information
| Provider Information | |||||||||
| NPI: | 1376541649 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VASAN | ||||||||
| FirstName: | SRINI | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 416 COLEGATE DR BLDG 3 | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 457509549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7405684814 | ||||||||
| FaxNumber: | 7403743165 | ||||||||
| Practice Location | |||||||||
| Address1: | 807 FARSON ST STE 116 | ||||||||
| Address2: | |||||||||
| City: | BELPRE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 457141068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403761960 | ||||||||
| FaxNumber: | 7403765037 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2005 | ||||||||
| LastUpdateDate: | 02/12/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | 13934 | WV | N | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 2085R0001X | 35.052348 | OH | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 0123692000 | 05 | WV | MEDICAID | 0576149 | 05 | OH | MEDICAID | 000000545268 | 01 | OH | ANTHEM | OTHER | 000000696934 | 01 | OH | ANTHEM | OTHER |