Healthcare Provider Details

I. General information

NPI: 1164559530
Provider Name (Legal Business Name): SREEDEVI CHENNUPATI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 09/01/2022
Certification Date: 09/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1425 PORTLAND AVE
ROCHESTER NY
14621-3001
US

IV. Provider business mailing address

1425 PORTLAND AVE BOX 242
ROCHESTER NY
14621-3001
US

V. Phone/Fax

Practice location:
  • Phone: 585-922-0400
  • Fax: 585-922-0455
Mailing address:
  • Phone: 585-922-0400
  • Fax: 585-922-0455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number233042
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: