Healthcare Provider Details

I. General information

NPI: 1578575270
Provider Name (Legal Business Name): SHANTHI SRINIVASAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 JESSE HILL JR DR SE GRADY HEALTH SYSTEM - GASTROENTEROLOGY
ATLANTA GA
30303-3031
US

IV. Provider business mailing address

80 JESSE HILL JR DR SE GRADY HEALTH SYSTEM - GASTROENTEROLOGY
ATLANTA GA
30303-3031
US

V. Phone/Fax

Practice location:
  • Phone: 404-616-4307
  • Fax:
Mailing address:
  • Phone: 404-616-4307
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number052637
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: