Basic Information
| Provider Information | |||||||||
| NPI: | 1558334573 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VISSA | ||||||||
| FirstName: | SRIRAM | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SRIRAM | ||||||||
| OtherFirstName: | VISSA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 12101 WOODCREST EXECUTIVE DR | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631415047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143170600 | ||||||||
| FaxNumber: | 3143170606 | ||||||||
| Practice Location | |||||||||
| Address1: | 12303 DE PAUL DR | ||||||||
| Address2: | |||||||||
| City: | BRIDGETON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630442512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143170600 | ||||||||
| FaxNumber: | 3143170606 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2006 | ||||||||
| LastUpdateDate: | 06/19/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 2004016757 | MO | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 2004016757 | MO | N | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 209220003 | 05 | MO | MEDICAID | 1558334573 | 05 | IL | MEDICAID |