=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740599109
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SRIKANTH NADELLA M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/04/2010
-----------------------------------------------------
Last Update Date | 08/28/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2133 VADALABENE DR STE 1
-----------------------------------------------------
City | MARYVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62062-5839
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-288-4350
-----------------------------------------------------
Fax | 618-288-4296
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6810 STATE ROUTE 162 BOX 215
-----------------------------------------------------
City | MARYVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62062
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-391-6495
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 2010033328
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------