Basic Information
| Provider Information | |||||||||
| NPI: | 1972522092 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SRIDHAR | ||||||||
| FirstName: | KOLLIPARA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7425 FORSYTH BLVD | ||||||||
| Address2: | C B 8221 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631052171 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143626973 | ||||||||
| FaxNumber: | 3143621185 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 BARNES JEWISH HOSPITAL PLZ | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631101003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143626973 | ||||||||
| FaxNumber: | 3143621185 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 12/17/2008 | ||||||||
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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 | 207L00000X | 2006000673 | MO | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 201390507 | 05 | MO | MEDICAID |