Basic Information
Provider Information | |||||||||
NPI: | 1427223346 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SRIRAM | ||||||||
FirstName: | CHENNI | ||||||||
MiddleName: | S | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4201 ST. ANTOINE - UHC 5D MAILBOX 226 | ||||||||
Address2: | UNIVERSITY PEDIATRICIANS | ||||||||
City: | DETROIT | ||||||||
State: | MI | ||||||||
PostalCode: | 482012153 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3137454405 | ||||||||
FaxNumber: | 3139660665 | ||||||||
Practice Location | |||||||||
Address1: | 3901 BEAUBIEN - 4TH FL | ||||||||
Address2: | CHILDRENS HOSPITAL OF MI | ||||||||
City: | DETROIT | ||||||||
State: | MI | ||||||||
PostalCode: | 48201 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3137455484 | ||||||||
FaxNumber: | 3139662423 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/23/2008 | ||||||||
LastUpdateDate: | 01/19/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MD449353 | PA | N |   | Allopathic & Osteopathic Physicians | Pediatrics |   | 208000000X | 57012940 | OH | N |   | Allopathic & Osteopathic Physicians | Pediatrics |   | 208000000X | 104900 | MN | N |   | Allopathic & Osteopathic Physicians | Pediatrics |   | 208000000X | 53481 | MN | N |   | Allopathic & Osteopathic Physicians | Pediatrics |   | 2080P0202X | 57012940 | MI | Y |   | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Cardiology |
ID Information
ID | Type | State | Issuer | Description | 102844225 | 05 | PA |   | MEDICAID |