Healthcare Provider Details

I. General information

NPI: 1407880941
Provider Name (Legal Business Name): SUNEETHA MORTHALA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DR. SUNEETHA KOLLI

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 06/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2233 CLEMSON RD
COLUMBIA SC
29229-8016
US

IV. Provider business mailing address

4611 HARD SCRABBLE RD SUITE 359
COLUMBIA SC
29229-8584
US

V. Phone/Fax

Practice location:
  • Phone: 803-462-2824
  • Fax: 803-386-0283
Mailing address:
  • Phone: 803-462-2824
  • Fax: 803-386-0283

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number28893
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number28893
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: