Healthcare Provider Details

I. General information

NPI: 1598714990
Provider Name (Legal Business Name): MAILVAGANAM SRIDHARAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 09/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1521 GULL RD
KALAMAZOO MI
49048-1640
US

IV. Provider business mailing address

5943 STADIUM DR STE 1
KALAMAZOO MI
49009-3016
US

V. Phone/Fax

Practice location:
  • Phone: 269-226-5165
  • Fax: 269-226-5166
Mailing address:
  • Phone: 269-552-2836
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301078343
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License Number4301078343
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: