1598067522 NPI number — PHANIVARDHAN REDDY BABIREDDY M.D

Table of content: PHANIVARDHAN REDDY BABIREDDY M.D (NPI 1598067522)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598067522 NPI number — PHANIVARDHAN REDDY BABIREDDY M.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BABIREDDY
Provider First Name:
PHANIVARDHAN
Provider Middle Name:
REDDY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1598067522
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/23/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
210 N KENILWORTH AVE APT 9
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OAK PARK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60302-2062
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-460-3440
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1111 SUPERIOR ST
Provider Second Line Business Practice Location Address:
101
Provider Business Practice Location Address City Name:
MELROSE PARK
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60160-4138
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-344-2161
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/23/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  125.055722 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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