Provider Demographics
NPI:1699766980
Name:POLINENI, SUBBARAO (MD)
Entity type:Individual
Prefix:DR
First Name:SUBBARAO
Middle Name:
Last Name:POLINENI
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 1:6 JUNGERMAN CIR
Mailing Address - Street 2:STE 107
Mailing Address - City:ST PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63376
Mailing Address - Country:US
Mailing Address - Phone:636-928-1696
Mailing Address - Fax:636-928-3115
Practice Address - Street 1:6 JUNGERMAN CIR
Practice Address - Street 2:STE 107
Practice Address - City:ST PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376
Practice Address - Country:US
Practice Address - Phone:636-928-1696
Practice Address - Fax:636-928-3115
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-04
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR79572086S0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0105XAllopathic & Osteopathic PhysiciansSurgerySurgery of the Hand
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO201653805Medicaid
MO000001963Medicare ID - Type Unspecified
MO201653805Medicaid