Provider Demographics
NPI:1467666834
Name:GANNAVARAM, SRILATHA KONDURI (MBBS)
Entity Type:Individual
Prefix:
First Name:SRILATHA
Middle Name:KONDURI
Last Name:GANNAVARAM
Suffix:
Gender:F
Credentials:MBBS
Other - Prefix:
Other - First Name:SRILATHA
Other - Middle Name:
Other - Last Name:KONDURI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:901 E. 104TH ST
Mailing Address - Street 2:MAILSTOP 400N
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64131
Mailing Address - Country:US
Mailing Address - Phone:816-502-7104
Mailing Address - Fax:816-932-9670
Practice Address - Street 1:20 NE SAINT LUKES BLVD
Practice Address - Street 2:STE. 350
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64086-6001
Practice Address - Country:US
Practice Address - Phone:816-347-5600
Practice Address - Fax:816-347-5674
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2019-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0436784208M00000X
MO2007023617207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1467666834Medicaid
MO1467666834Medicaid