Healthcare Provider Details

I. General information

NPI: 1073799433
Provider Name (Legal Business Name): MICHAEL SRINIVASA SRIDHAR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2008
Last Update Date: 05/20/2021
Certification Date: 05/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 DOCTORS DR
GREENVILLE SC
29605-5608
US

IV. Provider business mailing address

300 E MCBEE AVE FL 4
GREENVILLE SC
29601-2842
US

V. Phone/Fax

Practice location:
  • Phone: 864-797-7060
  • Fax: 864-797-7065
Mailing address:
  • Phone: 864-522-8603
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License Number36194
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: