Provider Demographics
NPI:1306145099
Name:TRIPATHY, SHREEPADA
Entity type:Individual
Prefix:
First Name:SHREEPADA
Middle Name:
Last Name:TRIPATHY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 N 9TH ST
Mailing Address - Street 2:PO BOX 19676
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62702-5303
Mailing Address - Country:US
Mailing Address - Phone:217-545-8000
Mailing Address - Fax:217-757-6519
Practice Address - Street 1:415 N 9TH ST
Practice Address - Street 2:SUITE 4W64
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-5303
Practice Address - Country:US
Practice Address - Phone:217-545-8000
Practice Address - Fax:217-757-6519
Is Sole Proprietor?:No
Enumeration Date:2011-03-21
Last Update Date:2016-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-139989208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036139989001Medicaid
ILF400288275Medicare PIN