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General NPI Number Information
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NPI Number | 1194045013
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Entity Type | Individual
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Provider Name | SRINIVAS MIRYANAM PT
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Gender | Male
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Dates
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Enumeration Date | 06/02/2010
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Last Update Date | 06/02/2010
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Provider Practice Location Address
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Address Line | 1600 LIBERTY ST
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City | COVINGTON
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State | IN
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Zip | 47932-1715
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Country | US
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Telephone | 765-793-4818
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Fax |
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Provider Business Mailing Address
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Address Line | 2320 N VERMILION ST APT 322
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City | DANVILLE
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State | IL
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Zip | 61832-1739
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Country | US
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Telephone | 205-381-1997
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 05010247A
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License Number State | IN
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Taxonomy #2
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 5501015050
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License Number State | MI
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