=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467666834
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SRILATHA KONDURI GANNAVARAM MBBS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/09/2007
-----------------------------------------------------
Last Update Date | 02/28/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20 NE SAINT LUKES BLVD STE. 350
-----------------------------------------------------
City | LEES SUMMIT
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64086-6001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-347-5600
-----------------------------------------------------
Fax | 816-347-5674
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 901 E. 104TH ST MAILSTOP 400N
-----------------------------------------------------
City | KANSAS CITY
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64131
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-502-7104
-----------------------------------------------------
Fax | 816-932-9670
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208M00000X
-----------------------------------------------------
Taxonomy Name | Hospitalist Physician
-----------------------------------------------------
License Number | 0436784
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 2007023617
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------