Basic Information
| Provider Information | |||||||||
| NPI: | 1467474726 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | POONAM SRIVASTAVA MD PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1575 N OLD TRAIL | ||||||||
| Address2: | |||||||||
| City: | SELINSGROVE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178701575 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5703748555 | ||||||||
| FaxNumber: | 5703749933 | ||||||||
| Practice Location | |||||||||
| Address1: | 1575 N OLD TRAIL | ||||||||
| Address2: | |||||||||
| City: | SELINSGROVE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178701575 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5703748555 | ||||||||
| FaxNumber: | 5703749933 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2006 | ||||||||
| LastUpdateDate: | 11/12/2010 | ||||||||
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| AuthorizedOfficialLastName: | SRIVASTAVA | ||||||||
| AuthorizedOfficialFirstName: | NAREN | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 5703748555 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | PA | N | Laboratories | Clinical Medical Laboratory | 207RH0003X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 1007421000005 | 05 | PA | MEDICAID | 1007421000009 | 05 | PA | MEDICAID |