Basic Information
| Provider Information | |||||||||
| NPI: | 1780811422 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SRINIVASAN | ||||||||
| FirstName: | LINE | ||||||||
| MiddleName: | JOHANSEN | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 800 W CENTRAL RD | ||||||||
| Address2: | |||||||||
| City: | ARLINGTON HEIGHTS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600052349 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 800 W CENTRAL RD | ||||||||
| Address2: | |||||||||
| City: | ARLINGTON HEIGHTS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600052349 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8476181000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2009 | ||||||||
| LastUpdateDate: | 10/11/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | BP10034486 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207L00000X | 036.131163 | IL | Y | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | 60028-20 | WI | N | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 1780811422 | 05 | WI | MEDICAID |