Basic Information
| Provider Information | |||||||||
| NPI: | 1619237971 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SRIDHARAN | ||||||||
| FirstName: | PRASANNA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 586 BOULDER POINT DR | ||||||||
| Address2: | |||||||||
| City: | CHAPEL HILL | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275164187 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9082277581 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1400 US HIGHWAY 61 | ||||||||
| Address2: | |||||||||
| City: | FESTUS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630284100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6369331000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2012 | ||||||||
| LastUpdateDate: | 09/16/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 2018-02972 | NC | Y | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | 01083665A | IN | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 2018-02972 | NC | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | D0081736 | MD | N | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.