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General NPI Number Information
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NPI Number | 1114219417
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Entity Type | Organization
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Legal Business Name | GATEWAY GERIATRIC SERVICES LLC
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Dates
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Enumeration Date | 05/05/2011
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Last Update Date | 07/13/2011
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Provider Practice Location Address
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Address Line | 12026 CONWAY RD
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City | SAINT LOUIS
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State | MO
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Zip | 63131-2417
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Country | US
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Telephone | 314-225-6015
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Fax |
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Provider Business Mailing Address
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Address Line | 12026 CONWAY RD
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City | SAINT LOUIS
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State | MO
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Zip | 63131-2417
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Country | US
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Telephone | 314-225-6015
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Fax |
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Authorized Official
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Title or Position | PHYSICIAN/PRESIDENT
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Name | SHAILAJA PULISETTY
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Credential | M.D.
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Telephone | 314-225-6015
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RG0300X
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Taxonomy Name | Geriatric Medicine (Internal Medicine) Physician
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License Number | 2005019644
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License Number State | MO
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