Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 036-133091 | IL |
N | 207Q00000X | Family Doctor | 53824 | WI |
NPI | 1003075318 |
---|---|
Provider Name | Srivani Sridhar |
First Address | Milwaukee, WI 53278-8866 |
Second Address | Rockford, IL 61114 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/06/2008 |
Last Update Date | 19/02/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
F400093213 | (02) | IL |