Provider Demographics
NPI:1629032081
Name:SUSEELA SAMUDRALA MD PC
Entity Type:Organization
Organization Name:SUSEELA SAMUDRALA MD PC
Other - Org Name:METRO REHAB PHYSICIANS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARINA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCROY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-355-7880
Mailing Address - Street 1:11125 DUNN ROAD
Mailing Address - Street 2:SUITE 311
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63136
Mailing Address - Country:US
Mailing Address - Phone:314-653-5730
Mailing Address - Fax:314-355-8899
Practice Address - Street 1:11125 DUNN ROAD
Practice Address - Street 2:SUITE 311
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63136
Practice Address - Country:US
Practice Address - Phone:314-653-5730
Practice Address - Fax:314-355-8899
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-13
Last Update Date:2010-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR8290208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO507527000Medicaid
MO507527000Medicaid
MO990000603Medicare ID - Type Unspecified