=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467474726
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | POONAM SRIVASTAVA MD PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/24/2006
-----------------------------------------------------
Last Update Date | 11/12/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1575 N OLD TRAIL
-----------------------------------------------------
City | SELINSGROVE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17870-1575
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-374-8555
-----------------------------------------------------
Fax | 570-374-9933
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1575 N OLD TRAIL
-----------------------------------------------------
City | SELINSGROVE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17870-1575
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-374-8555
-----------------------------------------------------
Fax | 570-374-9933
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MR. NAREN SRIVASTAVA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 570-374-8555
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RH0003X
-----------------------------------------------------
Taxonomy Name | Hematology & Oncology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------