Healthcare Provider Details

I. General information

NPI: 1609019900
Provider Name (Legal Business Name): SRISAI P C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2009
Last Update Date: 03/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7972 WEST JEFFERSON BLVD SUITE A
FORT WAYNE IN
46804-4140
US

IV. Provider business mailing address

7972 WEST JEFFERSON BLVD SUITE A
FORT WAYNE IN
46804-4140
US

V. Phone/Fax

Practice location:
  • Phone: 260-459-1780
  • Fax: 260-459-2779
Mailing address:
  • Phone: 260-459-1780
  • Fax: 260-459-2779

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01046950
License Number StateIN

VIII. Authorized Official

Name: ANURADHA KOLLIPARA
Title or Position: OWNER
Credential: M.D.
Phone: 260-459-1780