Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208200000X | Surgeon | 2018032445 | MO |
N | 208600000X | Surgeon | 2018032445 | MO |
Y | 2086S0102X | Surgical Critical Care | 2018032445 | MO |
N | 2086S0127X | Trauma Surgeon | 2018032445 | MO |
NPI | 1346531464 |
---|---|
Provider Name | Dr. Charlie Srivilasa |
First Address | Saint Louis, MO 63110-1010 |
Second Address | Saint Louis, MO 63108-1495 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/04/2011 |
Last Update Date | 15/11/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
200066167 | (05) | MO |