Basic Information
| Provider Information | |||||||||
| NPI: | 1063482636 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SRIDHARA | ||||||||
| FirstName: | BANGALORE | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20 GRAND STREET, 3RD FL | ||||||||
| Address2: | |||||||||
| City: | WARWICK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109901035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8459421001 | ||||||||
| FaxNumber: | 8459875979 | ||||||||
| Practice Location | |||||||||
| Address1: | 12 LIBERTY SQUARE MALL | ||||||||
| Address2: | |||||||||
| City: | STONY POINT | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109802400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8459421001 | ||||||||
| FaxNumber: | 8459421431 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2006 | ||||||||
| LastUpdateDate: | 01/11/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 213781 | NY | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 961385 | 01 | NY | MVP/TACONIC IPA | OTHER | 193679 | 01 | NY | WELLCARE | OTHER | 213781 | 01 | NY | CONNECTICARE | OTHER | 213781 | 01 | NY | HIP | OTHER | 700608 | 01 | NY | US FAMILY HEALTH PLAN | OTHER | 2386215 | 01 | NY | AETNA HMO | OTHER | P00114326 | 01 | NY | RAILROAD MEDICARE | OTHER | 01943466 | 05 | NY | MEDICAID | 58N891 | 01 | NY | EMPIRE BC STONY POINT | OTHER | N67450 | 01 | NY | HEALTHNET | OTHER | 000000045698 | 01 | NY | GHI HMO | OTHER | 133693126 | 01 | NY | TAX ID # | OTHER | P1979240 | 01 | NY | OXFORD | OTHER | 0181480 | 01 | NY | GHI PPO | OTHER | 58N892 | 01 | NY | EMPIRE BC WEST NYACK | OTHER | 7998110 | 01 | NY | AETNA PPO | OTHER |