Provider Demographics
NPI:1174590962
Name:CHAKRAVARTHI, SRINIVASACHARI TATADESIKA (MD)
Entity type:Individual
Prefix:
First Name:SRINIVASACHARI
Middle Name:TATADESIKA
Last Name:CHAKRAVARTHI
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:2200 JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43604-7101
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2222 CHERRY ST
Practice Address - Street 2:SUITE M200
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43608-2673
Practice Address - Country:US
Practice Address - Phone:419-251-8019
Practice Address - Fax:419-251-5819
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2015-09-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301084746207T00000X
OH35085008207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4685161Medicaid
OH0132377Medicaid
MI0999980OtherBAY HEALTH PLAN
MI1400910402OtherBCBSM
MI4753593Medicaid
MI4753637Medicaid
MI700Z946010OtherBCBSM
MI1013097OtherMCLAREN HEALTH PLAN
MI1013097OtherHEALTH ADVANTAGE NETWORK
MI700Z946010OtherCOMMUNITY BLUE PPO
MI700Z946010OtherBLUE CHOICE
MI0999980OtherHEALTH PLUS
MI700Z946010OtherBLUE CARE NETWORK
MI7344665OtherAETNA
OH0132377Medicaid