MEDICARE: SREEHARI SIVASUBRAMANIAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	5501012811	MI

General Provider Information

NPI Number	:	1619126265
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SREEHARI SIVASUBRAMANIAN

Provider Business Mailing Address
First Line	:	1960 28TH ST SE
Second Line	:	SUITE B
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49508-7900
Country	:	US
Telephone Number	:	616-475-9888
Fax Number	:	616-475-9889

Provider Business Practice Location Address
First Line	:	1960 28TH ST SE
Second Line	:	SUITE B
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49508-7900
Country	:	US
Telephone Number	:	616-475-9888
Fax Number	:	616-475-9889

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/18/2008
Last Update Date	:	09/18/2008

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