Basic Information
| Provider Information | |||||||||
| NPI: | 1740506229 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KANURI | ||||||||
| FirstName: | SRIDEVI | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SOMPALLI | ||||||||
| OtherFirstName: | SRIDEVI | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 620 W EDISON RD | ||||||||
| Address2: | STE 110 | ||||||||
| City: | MISHAWAKA | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465452784 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742581100 | ||||||||
| FaxNumber: | 5742581101 | ||||||||
| Practice Location | |||||||||
| Address1: | 620 W EDISON RD | ||||||||
| Address2: | STE 110 | ||||||||
| City: | MISHAWAKA | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465452784 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742581100 | ||||||||
| FaxNumber: | 5742581101 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2010 | ||||||||
| LastUpdateDate: | 08/24/2016 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 036123242 | IL | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085B0100X | 01069685A | IN | N | Allopathic & Osteopathic Physicians | Radiology | Body Imaging |
ID Information
| ID | Type | State | Issuer | Description | 201021510 | 05 | IN | MEDICAID |