Basic Information
| Provider Information | |||||||||
| NPI: | 1861745218 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARELLA | ||||||||
| FirstName: | SRIMANNARAYANA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6810 STATE ROUTE 162 BOX 215 | ||||||||
| Address2: | |||||||||
| City: | MARYVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620628501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6183916405 | ||||||||
| FaxNumber: | 6182884088 | ||||||||
| Practice Location | |||||||||
| Address1: | 6616 CENTER GROVE RD. | ||||||||
| Address2: | |||||||||
| City: | EDWARDSVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6186591599 | ||||||||
| FaxNumber: | 6186591597 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2012 | ||||||||
| LastUpdateDate: | 10/22/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 2013018498 | MO | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.