Basic Information
| Provider Information | |||||||||
| NPI: | 1013204296 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KOSURU | ||||||||
| FirstName: | KRISHNAMRAJU | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 504944 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631504944 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178294620 | ||||||||
| FaxNumber: | 4178294316 | ||||||||
| Practice Location | |||||||||
| Address1: | 3126 S JACKSON AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | JOPLIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648042534 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4175563416 | ||||||||
| FaxNumber: | 4175563417 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2011 | ||||||||
| LastUpdateDate: | 01/14/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 2015040888 | MO | Y | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 0437804 | KS | N | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 200622340A | 05 | OK | MEDICAID | 1013204296 | 05 | MO | MEDICAID | PENDING | 05 | KS | MEDICAID |