Basic Information
| Provider Information | |||||||||
| NPI: | 1770579922 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SRINIVASAN | ||||||||
| FirstName: | KRISHNAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1040 SIERRA DR | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | GREENWOOD | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461437240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175284800 | ||||||||
| FaxNumber: | 3178658319 | ||||||||
| Practice Location | |||||||||
| Address1: | 3900 W 203RD ST | ||||||||
| Address2: | |||||||||
| City: | OLYMPIA FIELDS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604611183 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7086792380 | ||||||||
| FaxNumber: | 7086792295 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2005 | ||||||||
| LastUpdateDate: | 03/20/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | 036-084652 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 1770579922 | 01 | NPI | OTHER | F400112794 | 01 | IL | MEDICARE PTAN | OTHER | 036-084-652 | 05 | IL | MEDICAID |