1245263524 NPI number — DR. SURENDER REDDY EDLA MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245263524 NPI number — DR. SURENDER REDDY EDLA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EDLA
Provider First Name:
SURENDER
Provider Middle Name:
REDDY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1245263524
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/03/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6020 RICHMOND HWY
Provider Second Line Business Mailing Address:
STE 102
Provider Business Mailing Address City Name:
ALEXANDRIA
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22303-2157
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
443-363-3953
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1790 OLD TRAIL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ETTERS
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17319-9652
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
717-938-6588
Provider Business Practice Location Address Fax Number:
717-938-9601
Provider Enumeration Date:
07/09/2006

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: 207Q00000X , with the licence number:  0101239065 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207Q00000X , with the licence number: MD429426 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 101677202 0001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7977899 . This is a "AETNA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 102470 . This is a "GEISINGER" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 889580 . This is a "CAREFIRST MD BCBS" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 187920 . This is a "UNISON-WMG" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1879312 . This is a "HIGHMARK BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 2157513 . This is a "MAMSI-WMG" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 50061854 . This is a "CAPITAL BLUE CROSS-WMG" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 50083184 . This is a "CAPITAL BLUE CROSS-WMG WFM" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: P006944 . This is a "GATEWAY-WMG" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 20055006 . This is a "AMERIHEALTH MERCY-WMG" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 205115 . This is a "JOHNS HOPKINS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 261035 . This is a "UNISON-WMG WFM" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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