Provider Demographics
NPI:1326034919
Name:KURELLA, SRIRAMA S (MD)
Entity Type:Individual
Prefix:DR
First Name:SRIRAMA
Middle Name:S
Last Name:KURELLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:S
Other - Middle Name:S
Other - Last Name:KURELLA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:390 MAPLE SUMMIT RD
Mailing Address - Street 2:PO BOX 279
Mailing Address - City:JERSEYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62052-2000
Mailing Address - Country:US
Mailing Address - Phone:618-498-7518
Mailing Address - Fax:618-498-3052
Practice Address - Street 1:390 MAPLE SUMMIT RD
Practice Address - Street 2:
Practice Address - City:JERSEYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62052-2000
Practice Address - Country:US
Practice Address - Phone:618-498-7518
Practice Address - Fax:618-498-3052
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2012-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36046971207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL784310OtherMEDICARE
IL036046971Medicaid
291740Medicare ID - Type Unspecified
IL784310OtherMEDICARE