Provider Demographics
NPI:1548355621
Name:KANUNGO, SRIRAJ T (MD)
Entity type:Individual
Prefix:
First Name:SRIRAJ
Middle Name:T
Last Name:KANUNGO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6810 STATE ROUTE 162
Mailing Address - Street 2:BOX 215
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062
Mailing Address - Country:US
Mailing Address - Phone:618-391-6495
Mailing Address - Fax:
Practice Address - Street 1:6812 STATE ROUTE 162 STE 121
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-8586
Practice Address - Country:US
Practice Address - Phone:618-391-5690
Practice Address - Fax:618-391-5691
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005018762207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO937564433Medicare ID - Type Unspecified