Healthcare Provider Details

I. General information

NPI: 1104111939
Provider Name (Legal Business Name): SRIHARSHA CHERUKUMILLI GREVICH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2011
Last Update Date: 09/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4800 SAND POINT WAY NE MA. 7.110
SEATTLE WA
98105-3901
US

IV. Provider business mailing address

4800 SAND POINT WAY NE MA. 7.110
SEATTLE WA
98105-3901
US

V. Phone/Fax

Practice location:
  • Phone: 407-353-7980
  • Fax:
Mailing address:
  • Phone: 407-353-7980
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA122484
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2080P0216X
TaxonomyPediatric Rheumatology Physician
License Number60457123
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: