Basic Information
| Provider Information | |||||||||
| NPI: | 1770686974 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SRIDHARA SASTRY MD PA | ||||||||
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| OtherOrganizationName: | PEDIATRIC CRITICAL CARE ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 21727 | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336221727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278232188 | ||||||||
| FaxNumber: | 7278239502 | ||||||||
| Practice Location | |||||||||
| Address1: | 5003 E LONGBOAT BLVD | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336154229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8138557884 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2006 | ||||||||
| LastUpdateDate: | 10/08/2012 | ||||||||
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| AuthorizedOfficialLastName: | SASTRY | ||||||||
| AuthorizedOfficialFirstName: | SRIDHARA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER / PROVIDER | ||||||||
| AuthorizedOfficialTelephone: | 8138557884 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0203X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 045861900 | 05 | FL | MEDICAID |