Healthcare Provider Details

I. General information

NPI: 1609065051
Provider Name (Legal Business Name): INFECTIOUS DISEASE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2007
Last Update Date: 02/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10004 KENNERLY RD SUITE 368B
SAINT LOUIS MO
63128-2141
US

IV. Provider business mailing address

1836 LACKLAND HILL PKWY ATTN: CREDENTIALING
SAINT LOUIS MO
63146-3572
US

V. Phone/Fax

Practice location:
  • Phone: 314-729-1570
  • Fax: 314-729-1575
Mailing address:
  • Phone: 314-872-1439
  • Fax: 314-810-1399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code364SA2100X
TaxonomyAcute Care Clinical Nurse Specialist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. SURESH NELLORE
Title or Position: AUTHORIZE OFFICIAL
Credential: MD
Phone: 314-729-1570