Healthcare Provider Details

I. General information

NPI: 1235751546
Provider Name (Legal Business Name): MANOJ HARI PALAVALLI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2020
Last Update Date: 03/19/2024
Certification Date: 03/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 S GRAND BLVD
SAINT LOUIS MO
63104-1016
US

IV. Provider business mailing address

1008 S SPRING AVE
SAINT LOUIS MO
63110-2520
US

V. Phone/Fax

Practice location:
  • Phone: 314-257-8000
  • Fax: 314-977-1664
Mailing address:
  • Phone: 314-977-2605
  • Fax: 314-977-1664

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number57.249192
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: