Basic Information
| Provider Information | |||||||||
| NPI: | 1881009538 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHUNCHULU | ||||||||
| FirstName: | SRIVANI | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1600 E EVERGREEN ST | ||||||||
| Address2: | |||||||||
| City: | CAMERON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 644292400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8166322101 | ||||||||
| FaxNumber: | 8166493383 | ||||||||
| Practice Location | |||||||||
| Address1: | 1007 S POLK ST | ||||||||
| Address2: | |||||||||
| City: | MAYSVILLE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 644694030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8164492123 | ||||||||
| FaxNumber: | 8164492125 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2014 | ||||||||
| LastUpdateDate: | 09/13/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 35.144406 | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 2017022845 | MO | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.