Healthcare Provider Details

I. General information

NPI: 1649582503
Provider Name (Legal Business Name): NISHANT SRINIVASAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2010
Last Update Date: 01/22/2024
Certification Date: 01/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3249 OAK PARK AVE
BERWYN IL
60402-3429
US

IV. Provider business mailing address

1500 S CALIFORNIA AVE F444
CHICAGO IL
60608-1729
US

V. Phone/Fax

Practice location:
  • Phone: 708-783-2226
  • Fax:
Mailing address:
  • Phone: 773-257-6183
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number125055748
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number036130726
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036130726
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: