Provider Demographics
NPI:1609065051
Name:INFECTIOUS DISEASE, PC
Entity Type:Organization
Organization Name:INFECTIOUS DISEASE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZE OFFICIAL
Authorized Official - Prefix:DR
Authorized Official - First Name:SURESH
Authorized Official - Middle Name:
Authorized Official - Last Name:NELLORE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-729-1570
Mailing Address - Street 1:1836 LACKLAND HILL PKWY
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146-3572
Mailing Address - Country:US
Mailing Address - Phone:314-872-1439
Mailing Address - Fax:314-810-1399
Practice Address - Street 1:10004 KENNERLY RD
Practice Address - Street 2:SUITE 368B
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2141
Practice Address - Country:US
Practice Address - Phone:314-729-1570
Practice Address - Fax:314-729-1575
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-22
Last Update Date:2008-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty
No364SA2100XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAcute CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO6016660002Medicare NSC