Provider Demographics
NPI:1053816900
Name:TALLURI, SRIHARSHA
Entity Type:Individual
Prefix:
First Name:SRIHARSHA
Middle Name:
Last Name:TALLURI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 CHESTNUT ST APT 453
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37402-4534
Mailing Address - Country:US
Mailing Address - Phone:717-659-7710
Mailing Address - Fax:
Practice Address - Street 1:979 E 3RD ST STE C-925
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37403-2136
Practice Address - Country:US
Practice Address - Phone:423-778-4691
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-23
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TN1053816900208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program