Provider Demographics
NPI:1306971015
Name:SRINIVAS RAO, GEORGINA (MD)
Entity type:Individual
Prefix:
First Name:GEORGINA
Middle Name:
Last Name:SRINIVAS RAO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1024 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-1745
Mailing Address - Country:US
Mailing Address - Phone:630-262-2640
Mailing Address - Fax:630-262-2645
Practice Address - Street 1:1024 W MAIN ST
Practice Address - Street 2:
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-1745
Practice Address - Country:US
Practice Address - Phone:630-262-2640
Practice Address - Fax:630-262-2645
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360988892084P0800X, 2084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL4532713OtherBCBS
IL036059492Medicaid