1013204296 NPI number — KRISHNAMRAJU KOSURU M.D

Table of content: KRISHNAMRAJU KOSURU M.D (NPI 1013204296)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013204296 NPI number — KRISHNAMRAJU KOSURU M.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOSURU
Provider First Name:
KRISHNAMRAJU
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013204296
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/14/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 504944
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63150-4944
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-829-4620
Provider Business Mailing Address Fax Number:
417-829-4316

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3126 S JACKSON AVE
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
JOPLIN
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64804-2534
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-556-3416
Provider Business Practice Location Address Fax Number:
417-556-3417
Provider Enumeration Date:
07/07/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  2015040888 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208000000X , with the licence number: 0437804 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 200622340A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1013204296 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: PENDING , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".




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