Healthcare Provider Details

I. General information

NPI: 1114210390
Provider Name (Legal Business Name): SANTHISRI KODALI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2011
Last Update Date: 07/18/2023
Certification Date: 07/18/2023
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: 573-629-3500
  • Fax: 573-629-3314
Mailing address:
  • Phone: 573-629-3300
  • Fax: 573-629-3314

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number2023025438
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberBP10040647
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberS4010
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number2023025438
License Number StateMO
# 5
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License NumberS4010
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: