1285613901 NPI number — DR. SORA H REDDY M.D.

Table of content: DR. SORA H REDDY M.D. (NPI 1285613901)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285613901 NPI number — DR. SORA H REDDY M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
REDDY
Provider First Name:
SORA
Provider Middle Name:
H
Provider Name Prefix Text:
DR.
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:
1285613901
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/09/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1236 E RUSHOLME ST STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DAVENPORT
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52803-2473
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
563-324-2992
Provider Business Mailing Address Fax Number:
563-324-8562

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1100 36TH AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOLINE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61265
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-743-6700
Provider Business Practice Location Address Fax Number:
309-764-2042
Provider Enumeration Date:
01/11/2006

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: 207RI0011X , with the licence number:  036092650 , 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)

  • Identifier: 036092650 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4141408 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00180487 . This is a "MEDICARE RAILROAD" identifier . This identifiers is of the category "OTHER".




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