Healthcare Provider Details

I. General information

NPI: 1376579698
Provider Name (Legal Business Name): SRINATH CHINNAKOTLA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2006
Last Update Date: 11/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 DELAWARE ST SE
MINNEAPOLIS MN
55455-0356
US

IV. Provider business mailing address

420 DELAWARE ST SE MMC 195
MINNEAPOLIS MN
55455-0341
US

V. Phone/Fax

Practice location:
  • Phone: 612-626-6100
  • Fax:
Mailing address:
  • Phone: 612-625-3373
  • Fax: 612-624-7168

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204F00000X
TaxonomyTransplant Surgery Physician
License NumberL2843
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code204F00000X
TaxonomyTransplant Surgery Physician
License Number52651
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: