Healthcare Provider Details

I. General information

NPI: 1497037253
Provider Name (Legal Business Name): GURUSARAVANAN KUTTI SRIDHARAN M.D.,
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2011
Last Update Date: 09/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 W PARK ST
URBANA IL
61801-2500
US

IV. Provider business mailing address

611 W PARK ST
URBANA IL
61801-2500
US

V. Phone/Fax

Practice location:
  • Phone: 217-383-3110
  • Fax: 217-244-0621
Mailing address:
  • Phone: 217-383-3110
  • Fax: 217-244-0621

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125059646
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: