Healthcare Provider Details

I. General information

NPI: 1326034919
Provider Name (Legal Business Name): SRIRAMA S KURELLA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: S S KURELLA M.D.

II. Dates (important events)

Enumeration Date: 09/20/2005
Last Update Date: 04/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

390 MAPLE SUMMIT RD
JERSEYVILLE IL
62052-2000
US

IV. Provider business mailing address

390 MAPLE SUMMIT RD PO BOX 279
JERSEYVILLE IL
62052-2000
US

V. Phone/Fax

Practice location:
  • Phone: 618-498-7518
  • Fax: 618-498-3052
Mailing address:
  • Phone: 618-498-7518
  • Fax: 618-498-3052

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number36046971
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: