Healthcare Provider Details

I. General information

NPI: 1538332689
Provider Name (Legal Business Name): SRIDIVYA KUMAR M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2008
Last Update Date: 10/31/2022
Certification Date: 10/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 E 80TH PL UNIT 2
MERRILLVILLE IN
46410-5671
US

IV. Provider business mailing address

PO BOX 3877
JOLIET IL
60434-3877
US

V. Phone/Fax

Practice location:
  • Phone: 219-472-0379
  • Fax: 219-472-0491
Mailing address:
  • Phone: 815-741-6830
  • Fax: 815-741-6832

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number01073307A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: