Provider Demographics
NPI:1407058563
Name:TALLURI, SIVA (MD)
Entity Type:Individual
Prefix:DR
First Name:SIVA
Middle Name:
Last Name:TALLURI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 S. BALLENGER HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-3638
Mailing Address - Country:US
Mailing Address - Phone:810-342-2000
Mailing Address - Fax:810-342-1591
Practice Address - Street 1:3230 BEECHER RD
Practice Address - Street 2:SUITE 2
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-3638
Practice Address - Country:US
Practice Address - Phone:810-342-5800
Practice Address - Fax:810-342-5810
Is Sole Proprietor?:No
Enumeration Date:2007-06-01
Last Update Date:2012-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35089141207R00000X
MI4301089223207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1407058563Medicaid
OH35089141OtherOHIO LICENSE #