Provider Demographics
NPI:1518242957
Name:MANNEM, SANTHOSH REDDY (MD)
Entity Type:Individual
Prefix:
First Name:SANTHOSH
Middle Name:REDDY
Last Name:MANNEM
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:PO BOX 1257
Mailing Address - Street 2:
Mailing Address - City:HANNIBAL
Mailing Address - State:MO
Mailing Address - Zip Code:63401-1257
Mailing Address - Country:US
Mailing Address - Phone:573-629-3300
Mailing Address - Fax:573-629-3314
Practice Address - Street 1:6500 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:HANNIBAL
Practice Address - State:MO
Practice Address - Zip Code:63401-6890
Practice Address - Country:US
Practice Address - Phone:573-629-3300
Practice Address - Fax:573-629-3315
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-17
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD-17433207R00000X
390200000X
MO2020040841207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program