1023267945 NPI number — VLSR MADIREDDY MD PC

Table of content: (NPI 1023267945)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023267945 NPI number — VLSR MADIREDDY MD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VLSR MADIREDDY MD PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1023267945
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/09/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1715 HAMILTON DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BLOOMFIELD
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48302-0222
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
517-803-4544
Provider Business Mailing Address Fax Number:
517-803-4509

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4129 OKEMOS RD
Provider Second Line Business Practice Location Address:
STE 6
Provider Business Practice Location Address City Name:
OKEMOS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48864-2822
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-803-4544
Provider Business Practice Location Address Fax Number:
517-803-4509
Provider Enumeration Date:
09/16/2008

Additional Information

Authorized Official

Authorized Official Last Name:
MADIREDDY
Authorized Official First Name:
SRINIVASA
Authorized Official Middle Name:
R
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
248-214-1576

Provider Taxonomy Codes

  • Taxonomy code: 207QG0300X , with the licence number:  4301084372 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: DO5269 . This is a "RR MCR" identifier . This identifiers is of the category "OTHER".
  • Identifier: 10232267945 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0C30642 . This is a "BCBSM" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0C30644 . This is a "BCBSM NPP GRP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: SM084372 . This is a "STATE LIC#" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 080F369400 . This is a "BCBSM" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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