Basic Information
| Provider Information | |||||||||
| NPI: | 1609065051 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INFECTIOUS DISEASE, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1836 LACKLAND HILL PKWY | ||||||||
| Address2: | ATTN: CREDENTIALING | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631463572 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3148721439 | ||||||||
| FaxNumber: | 3148101399 | ||||||||
| Practice Location | |||||||||
| Address1: | 10004 KENNERLY RD | ||||||||
| Address2: | SUITE 368B | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631282141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3147291570 | ||||||||
| FaxNumber: | 3147291575 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/22/2007 | ||||||||
| LastUpdateDate: | 02/18/2008 | ||||||||
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| AuthorizedOfficialLastName: | NELLORE | ||||||||
| AuthorizedOfficialFirstName: | SURESH | ||||||||
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| AuthorizedOfficialTitleorPosition: | AUTHORIZE OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 3147291570 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | 364SA2100X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Acute Care | 207RI0200X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
No ID Information.