Healthcare Provider Details

I. General information

NPI: 1710179908
Provider Name (Legal Business Name): KISHORE K SRIRAM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2007
Last Update Date: 08/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 N HARRISON ST
WARSAW IN
46580-3163
US

IV. Provider business mailing address

850 N HARRISON ST
WARSAW IN
46580-3163
US

V. Phone/Fax

Practice location:
  • Phone: 574-267-7169
  • Fax: 574-269-3995
Mailing address:
  • Phone: 574-267-7169
  • Fax: 574-269-0597

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number2007016061
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number01070060A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: