Provider Demographics
NPI:1134352396
Name:SOUTH COUNTY INTERNAL MEDICINE PHYSICIANS, LLC
Entity type:Organization
Organization Name:SOUTH COUNTY INTERNAL MEDICINE PHYSICIANS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:RATAN
Authorized Official - Middle Name:K
Authorized Official - Last Name:NALLAMOTHU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:636-579-6148
Mailing Address - Street 1:12342 SPANISH TRACE DR
Mailing Address - Street 2:
Mailing Address - City:MARYLAND HEIGHTS
Mailing Address - State:MO
Mailing Address - Zip Code:63043-2306
Mailing Address - Country:US
Mailing Address - Phone:314-542-3686
Mailing Address - Fax:888-756-6714
Practice Address - Street 1:1479 HIGHWAY 61
Practice Address - Street 2:SUITE A
Practice Address - City:FESTUS
Practice Address - State:MO
Practice Address - Zip Code:63028-4109
Practice Address - Country:US
Practice Address - Phone:636-579-6148
Practice Address - Fax:888-756-6714
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-03
Last Update Date:2009-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009008003261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care