Basic Information
| Provider Information | |||||||||
| NPI: | 1740586171 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | TIRUMALA | ||||||||
| FirstName: | SRIDHAR | ||||||||
| MiddleName: | REDDY | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 5310 | ||||||||
| Address2: | DEPARTMENT OF ANESTHESIOLOGY | ||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711355310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3186755000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1501 KINGS HWY | ||||||||
| Address2: | DEPARTMENT OF ANESTHESIOLOGY | ||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711034228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3186755000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2011 | ||||||||
| LastUpdateDate: | 05/07/2014 | ||||||||
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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 | 207L00000X | MD.205973 | LA | Y | Allopathic & Osteopathic Physicians | Anesthesiology | 207LC0200X | MD.205973 | LA | N | Allopathic & Osteopathic Physicians | Anesthesiology | Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 295560YH54 | 01 | LA | MEDICARE - PTAN | OTHER | 2342169 | 05 | LA | MEDICAID | 295560YJQN | 01 | LA | MEDICARE - PTAN | OTHER |