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1184074601

NPI Code Detail

MEDICARE: SURYA SRIVIDYA PETLA MD

MEDICARE: SURYA SRIVIDYA PETLA MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208M00000X	Hospitalist Physician	CP1898	NE
2	207R00000X	Internal Medicine Physician	31173	WV
3	208000000X	Pediatrics Physician	31173	WV
4	208M00000X	Hospitalist Physician	MD-56311	IA

General Provider Information

NPI Number	:	1184074601
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SURYA SRIVIDYA PETLA MD

Provider Business Mailing Address
First Line	:	7500 MERCY RD
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68124-2319
Country	:	US
Telephone Number	:	855-524-4001
Fax Number	:	402-398-5589

Provider Business Practice Location Address
First Line	:	7500 MERCY RD
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68124-2319
Country	:	US
Telephone Number	:	855-524-4001
Fax Number	:	402-398-5589

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/15/2016
Last Update Date	:	01/20/2026

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Directions to “ SURYA SRIVIDYA PETLA MD” Practice Location

Language	Start Address	Practice Location

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