Provider Demographics
NPI:1932201290
Name:PERIYANAYAGAM, SRINIVASAN (MD)
Entity type:Individual
Prefix:
First Name:SRINIVASAN
Middle Name:
Last Name:PERIYANAYAGAM
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 1:390 W 17TH ST
Mailing Address - Street 2:
Mailing Address - City:HOPKINSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42240-1914
Mailing Address - Country:US
Mailing Address - Phone:270-886-1944
Mailing Address - Fax:270-886-2372
Practice Address - Street 1:390 W 17TH ST
Practice Address - Street 2:
Practice Address - City:HOPKINSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42240-1914
Practice Address - Country:US
Practice Address - Phone:270-886-1944
Practice Address - Fax:270-886-2372
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY24512207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64245129Medicaid
KY64245129Medicaid
1587301Medicare ID - Type Unspecified