Basic Information
| Provider Information | |||||||||
| NPI: | 1528014651 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | VASUDEVAN | ||||||||
| FirstName: | SRIDHAR | ||||||||
| MiddleName: | V. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | W129N7055 NORTHFIELD DR | ||||||||
| Address2: | PHYSICAL MEDICINE AND REHABILITATION | ||||||||
| City: | MENOMONEE FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530510538 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2622535400 | ||||||||
| FaxNumber: | 2622537162 | ||||||||
| Practice Location | |||||||||
| Address1: | W129N7055 NORTHFIELD DR | ||||||||
| Address2: | PHYSICAL MEDICINE AND REHABILITATION | ||||||||
| City: | MENOMONEE FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530510538 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2622535400 | ||||||||
| FaxNumber: | 2622537162 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2006 | ||||||||
| LastUpdateDate: | 09/06/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 20559 | WI | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 1528014651 | 05 | WI | MEDICAID |