Healthcare Provider Details

I. General information

NPI: 1881658292
Provider Name (Legal Business Name): SUSEELA SAMUDRALA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11125 DUNN RD SUITE 311
SAINT LOUIS MO
63136-6132
US

IV. Provider business mailing address

11125 DUNN RD
SAINT LOUIS MO
63136-6132
US

V. Phone/Fax

Practice location:
  • Phone: 314-355-7880
  • Fax: 314-355-8899
Mailing address:
  • Phone: 314-355-7880
  • Fax: 314-355-8899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberR8290
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: