MEDICARE: DR. SRINIVASU KUSUMA 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	207X00000X	Orthopaedic Surgery Physician	036.135648	IL

General Provider Information

NPI Number	:	1689839532
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SRINIVASU KUSUMA M.D.

Provider Business Mailing Address
First Line	:	27702 NETWORK PL
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60673-1277
Country	:	US
Telephone Number	:	708-862-7674
Fax Number	:	708-682-1781

Provider Business Practice Location Address
First Line	:	1600 167TH ST STE 900
Second Line	:
City	:	CALUMET CITY
State	:	IL
Zip	:	60409-5407
Country	:	US
Telephone Number	:	708-647-7565
Fax Number	:

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

Provider Enumeration Date	:	07/21/2008
Last Update Date	:	07/21/2022

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