Provider Demographics
NPI:1376745117
Name:BEERAVOLU, LAKSHMI R (MD)
Entity Type:Individual
Prefix:
First Name:LAKSHMI
Middle Name:R
Last Name:BEERAVOLU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4550 MEMORIAL DR
Mailing Address - Street 2:STE. A480
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62226-5372
Mailing Address - Country:US
Mailing Address - Phone:618-234-4531
Mailing Address - Fax:618-234-4695
Practice Address - Street 1:4550 MEMORIAL DR
Practice Address - Street 2:STE. A480
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62226-5372
Practice Address - Country:US
Practice Address - Phone:618-234-4531
Practice Address - Fax:618-234-4695
Is Sole Proprietor?:No
Enumeration Date:2007-06-04
Last Update Date:2014-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361313872084N0600X
MO20140298512084N0400X, 2084N0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL3521038Medicare PIN