Healthcare Provider Details

I. General information

NPI: 1770071706
Provider Name (Legal Business Name): SIVARAM PRABHUJI MUPPANENI M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2018
Last Update Date: 11/03/2022
Certification Date: 11/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

SSM ST MARY'S HOSPITAL 6420 CLAYTON ROAD
ST. LOUIS MO
63117
US

IV. Provider business mailing address

32-186, VASAVINAGAR
ADDANKI, PRAKASAM (DST) ANDHRA PRADESH
523201
IN

V. Phone/Fax

Practice location:
  • Phone: 314-768-8778
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0444982
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: