Provider Demographics
NPI:1578694881
Name:SRI D. KOLLI, M.D., P.C.
Entity Type:Organization
Organization Name:SRI D. KOLLI, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:WHITENER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-525-4934
Mailing Address - Street 1:10004 KENNERLY RD
Mailing Address - Street 2:SUITE 330A
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-2141
Mailing Address - Country:US
Mailing Address - Phone:314-525-4520
Mailing Address - Fax:314-525-4521
Practice Address - Street 1:10004 KENNERLY RD
Practice Address - Street 2:SUITE 330A
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2141
Practice Address - Country:US
Practice Address - Phone:314-525-4520
Practice Address - Fax:314-525-4521
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO109530207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MODA8462OtherRAILROAD MEDICARE
MODA8462OtherRAILROAD MEDICARE