Basic Information
| Provider Information | |||||||||
| NPI: | 1700016763 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ALLA | ||||||||
| FirstName: | SRIDEVI | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 864 WILSON DR | ||||||||
| Address2: | SUITE C | ||||||||
| City: | RIDGELAND | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391574512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012066100 | ||||||||
| FaxNumber: | 6012066052 | ||||||||
| Practice Location | |||||||||
| Address1: | 332 HIGHWAY 12 W | ||||||||
| Address2: | |||||||||
| City: | KOSCIUSKO | ||||||||
| State: | MS | ||||||||
| PostalCode: | 390903209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6622891800 | ||||||||
| FaxNumber: | 6622892489 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2009 | ||||||||
| LastUpdateDate: | 04/03/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 22172 | MS | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 05188833 | 05 | MS | MEDICAID |