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General NPI Number Information
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NPI Number | 1134352396
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Entity Type | Organization
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Legal Business Name | SOUTH COUNTY INTERNAL MEDICINE PHYSICIANS, LLC
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Dates
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Enumeration Date | 09/03/2009
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Last Update Date | 09/03/2009
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Provider Practice Location Address
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Address Line | 1479 HIGHWAY 61 SUITE A
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City | FESTUS
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State | MO
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Zip | 63028-4109
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Country | US
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Telephone | 636-579-6148
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Fax | 888-756-6714
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Provider Business Mailing Address
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Address Line | 12342 SPANISH TRACE DR
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City | MARYLAND HEIGHTS
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State | MO
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Zip | 63043-2306
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Country | US
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Telephone | 314-542-3686
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Fax | 888-756-6714
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Authorized Official
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Title or Position | PHYSICIAN
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Name | DR. RATAN K NALLAMOTHU
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Credential | M.D
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Telephone | 636-579-6148
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | 2009008003
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License Number State | MO
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