Provider Demographics
NPI:1528099090
Name:KOTAY, SREENIVASAN C (MD)
Entity type:Individual
Prefix:
First Name:SREENIVASAN
Middle Name:C
Last Name:KOTAY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:999 EXECUTIVE PARK BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-4632
Mailing Address - Country:US
Mailing Address - Phone:423-224-3250
Mailing Address - Fax:423-224-3258
Practice Address - Street 1:1763 PARK AVE SW
Practice Address - Street 2:
Practice Address - City:NORTON
Practice Address - State:VA
Practice Address - Zip Code:24273-1608
Practice Address - Country:US
Practice Address - Phone:276-679-1700
Practice Address - Fax:276-679-6243
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2012-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101031294207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010146670Medicaid
VA007372W65Medicare PIN
VA017126W82Medicare PIN
C36488Medicare UPIN
VA010146670Medicaid
VAP00640957Medicare PIN