MEDICARE: SRIDHAR VALLABHANENI M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208100000X	Physical Medicine & Rehabilitation Physician	01074949A	IN
2	208100000X	Physical Medicine & Rehabilitation Physician	036.137251	IL
3	208100000X	Physical Medicine & Rehabilitation Physician	72134	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	12591405	OTHER	IL	CAQH
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1164740122
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SRIDHAR VALLABHANENI M.D.

Provider Business Mailing Address
First Line	:	PO BOX 735044
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60673-5044
Country	:	US
Telephone Number	:	800-326-2250
Fax Number	:

Provider Business Practice Location Address
First Line	:	2901 W KINNICKINNIC RIVER PKWY STE 310
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53215-5643
Country	:	US
Telephone Number	:	414-649-3300
Fax Number	:	414-649-7012

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/14/2010
Last Update Date	:	12/11/2025

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