Healthcare Provider Details

I. General information

NPI: 1740506229
Provider Name (Legal Business Name): SRIDEVI KANURI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SRIDEVI SOMPALLI M.D.

II. Dates (important events)

Enumeration Date: 04/09/2010
Last Update Date: 08/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 W EDISON RD STE 110
MISHAWAKA IN
46545-2784
US

IV. Provider business mailing address

620 W EDISON RD STE 110
MISHAWAKA IN
46545-2784
US

V. Phone/Fax

Practice location:
  • Phone: 574-258-1100
  • Fax: 574-258-1101
Mailing address:
  • Phone: 574-258-1100
  • Fax: 574-258-1101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number036123242
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number01069685A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: