Healthcare Provider Details

I. General information

NPI: 1184074601
Provider Name (Legal Business Name): SURYA SRIVIDYA PETLA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2016
Last Update Date: 09/14/2022
Certification Date: 09/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6000 MEMORIAL CHURCH DR STE A
MORGANTOWN WV
26501-1503
US

IV. Provider business mailing address

6000 MEMORIAL CHURCH DR STE A
MORGANTOWN WV
26501-1503
US

V. Phone/Fax

Practice location:
  • Phone: 304-598-7313
  • Fax: 304-598-7319
Mailing address:
  • Phone: 304-598-7313
  • Fax: 304-598-7319

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number31173
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number31173
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: