Healthcare Provider Details

I. General information

NPI: 1700316528
Provider Name (Legal Business Name): SAI SIVA RAM GUDURU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2017
Last Update Date: 10/09/2024
Certification Date: 10/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5325 FARAON ST
SAINT JOSEPH MO
64506-3488
US

IV. Provider business mailing address

5301 FARAON ST STE 120
SAINT JOSEPH MO
64506-3512
US

V. Phone/Fax

Practice location:
  • Phone: 816-271-6406
  • Fax: 816-271-7986
Mailing address:
  • Phone: 816-271-6000
  • Fax: 816-271-6538

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number2020019634
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2020019634
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: