Healthcare Provider Details

I. General information

NPI: 1316947997
Provider Name (Legal Business Name): ARVIND SRINIVASAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2005
Last Update Date: 05/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 N. SHERMAN CT
HAZLETON PA
18201
US

IV. Provider business mailing address

1009 FOWLER AVE
BERWICK PA
18603-2305
US

V. Phone/Fax

Practice location:
  • Phone: 570-450-6333
  • Fax: 570-450-6571
Mailing address:
  • Phone: 570-759-6491
  • Fax: 570-759-2440

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberMD051265L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number25MA10291400
License Number StateNJ

VII. Legacy identifiers

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

# 1
Identifier001715561004
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer
# 2
Identifier0017155610004
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: