Provider Demographics
NPI:1760626063
Name:CHARYALU, MADDALITHIRUMALA S (MD)
Entity Type:Individual
Prefix:
First Name:MADDALITHIRUMALA
Middle Name:S
Last Name:CHARYALU
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 1:12125 WOODCREST EXECUTIVE DR
Mailing Address - Street 2:SUITE 220
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-5001
Mailing Address - Country:US
Mailing Address - Phone:314-317-0600
Mailing Address - Fax:314-317-0606
Practice Address - Street 1:2001 VAIL AVE FL 7
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1219
Practice Address - Country:US
Practice Address - Phone:314-317-0600
Practice Address - Fax:314-317-0606
Is Sole Proprietor?:No
Enumeration Date:2009-04-30
Last Update Date:2009-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2009-00699207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist