Healthcare Provider Details

I. General information

NPI: 1629032081
Provider Name (Legal Business Name): SUSEELA SAMUDRALA MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2006
Last Update Date: 04/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11125 DUNN ROAD SUITE 311
ST LOUIS MO
63136
US

IV. Provider business mailing address

11125 DUNN ROAD SUITE 311
ST LOUIS MO
63136
US

V. Phone/Fax

Practice location:
  • Phone: 314-653-5730
  • Fax: 314-355-8899
Mailing address:
  • Phone: 314-653-5730
  • 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: MARINA MCROY
Title or Position: OFFICE MANAGER
Credential:
Phone: 314-355-7880