Healthcare Provider Details

I. General information

NPI: 1356344402
Provider Name (Legal Business Name): MANOJ SRINATH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

235 MEDICAL PARK BLVD
BRISTOL TN
37620-7455
US

IV. Provider business mailing address

135 W RAVINE RD STE 3-A
KINGSPORT TN
37660-3847
US

V. Phone/Fax

Practice location:
  • Phone: 423-274-6350
  • Fax: 423-274-6354
Mailing address:
  • Phone: 423-246-6777
  • Fax: 423-246-7766

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number035088
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number0101230824
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberMD 35088
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: