Healthcare Provider Details

I. General information

NPI: 1356370266
Provider Name (Legal Business Name): SRIRAM S NARSIPUR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2006
Last Update Date: 10/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 PRESIDENTIAL PLZ FIRM C
SYRACUSE NY
13202-2240
US

IV. Provider business mailing address

90 PRESIDENTIAL PLZ FIRM C
SYRACUSE NY
13202-2240
US

V. Phone/Fax

Practice location:
  • Phone: 315-464-3834
  • Fax: 315-464-3837
Mailing address:
  • Phone: 315-464-3834
  • Fax: 315-464-3837

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0210X
TaxonomyPediatric Nephrology Physician
License Number203228
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number203228
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier01657345
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: