1093075038 NPI number — MS. SREELAKSHMI REDDIVARI PA

Table of content: MS. SREELAKSHMI REDDIVARI PA (NPI 1093075038)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093075038 NPI number — MS. SREELAKSHMI REDDIVARI PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
REDDIVARI
Provider First Name:
SREELAKSHMI
Provider Middle Name:
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
F

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:
1093075038
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/11/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
263 FARMINGTON AVE
Provider Second Line Business Mailing Address:
PROVIDER ENROLLMENT OFFICE, MC2212
Provider Business Mailing Address City Name:
FARMINGTON
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06030-2212
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-679-7503
Provider Business Mailing Address Fax Number:
860-679-1610

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
263 FARMINGTON AVE
Provider Second Line Business Practice Location Address:
GENERAL SURGERY
Provider Business Practice Location Address City Name:
FARMINGTON
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06030-6227
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-679-8080
Provider Business Practice Location Address Fax Number:
860-679-1420
Provider Enumeration Date:
05/24/2012

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: 363AS0400X , with the licence number:  002736 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1093075038 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




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