Healthcare Provider Details

I. General information

NPI: 1790781938
Provider Name (Legal Business Name): INDRA SRIRAM M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: INDRAMBIKAI SRIRAM M.D.

II. Dates (important events)

Enumeration Date: 06/22/2005
Last Update Date: 07/10/2014
Certification Date:
Deactivation Date: 03/15/2006
Reactivation Date: 03/28/2006

III. Provider practice location address

168 CAROLINA RIDGE DR
COLUMBIA SC
29229-7396
US

IV. Provider business mailing address

168 CAROLINA RIDGE DR
COLUMBIA SC
29229-7396
US

V. Phone/Fax

Practice location:
  • Phone: 260-602-4645
  • Fax:
Mailing address:
  • Phone: 260-602-4645
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RA0000X
TaxonomyAdolescent Medicine (Internal Medicine) Physician
License Number01040404
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number01040404
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code207RA0000X
TaxonomyAdolescent Medicine (Internal Medicine) Physician
License NumberMMD.36130 MD
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: