Healthcare Provider Details

I. General information

NPI: 1780068437
Provider Name (Legal Business Name): PRIYANKA YERRAGORLA MD, MSC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2015
Last Update Date: 10/12/2021
Certification Date: 10/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6500 HOSPITAL DR
HANNIBAL MO
63401-6890
US

IV. Provider business mailing address

6500 HOSPITAL DR
HANNIBAL MO
63401-6890
US

V. Phone/Fax

Practice location:
  • Phone: 673-629-3400
  • Fax: 675-629-3414
Mailing address:
  • Phone: 573-629-3400
  • Fax: 573-629-3414

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2021020039
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD16279
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: