Basic Information
| Provider Information | |||||||||
| NPI: | 1720088768 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHIRUMAMILLA | ||||||||
| FirstName: | SREE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 22 SAW MILL RIVER RD | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | HAWTHORNE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105321533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9145937513 | ||||||||
| FaxNumber: | 9144931281 | ||||||||
| Practice Location | |||||||||
| Address1: | 19 BRADHURST AVE | ||||||||
| Address2: | SUITE 1400 | ||||||||
| City: | HAWTHORNE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105322144 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9144937513 | ||||||||
| FaxNumber: | 9144931281 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2005 | ||||||||
| LastUpdateDate: | 01/27/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0203X | R5100 | TX | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine | 2080P0203X | 256469 | NY | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02717802 | 05 | NY | MEDICAID |