Healthcare Provider Details

I. General information

NPI: 1568637833
Provider Name (Legal Business Name): KRISHNASWAMI SRIRAM M. D.,
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2008
Last Update Date: 04/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 HUNTER LN
LAKE FOREST IL
60045-4905
US

IV. Provider business mailing address

611 HUNTER LN
LAKE FOREST IL
60045-4905
US

V. Phone/Fax

Practice location:
  • Phone: 847-615-2273
  • Fax:
Mailing address:
  • Phone: 847-615-2273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number036088401
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: