Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2086S0105X | Surgery of the Hand | R7957 | MO |
NPI | 1699766980 |
---|---|
Provider Name | Dr. Subbarao Polineni |
First Address | St Peters, MO 63376 |
Second Address | St Peters, MO 63376 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 04/11/2005 |
Last Update Date | 21/11/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
201653805 | (05) | MO |
A10154 | (02) |