1295774305 NPI number — SHYLA REDDY MD

Table of content: SHYLA REDDY MD (NPI 1295774305)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295774305 NPI number — SHYLA REDDY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
REDDY
Provider First Name:
SHYLA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1295774305
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/10/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1385
Provider Second Line Business Mailing Address:
P O BOX 1385
Provider Business Mailing Address City Name:
ALPHARETTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30009-1385
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-619-1974
Provider Business Mailing Address Fax Number:
678-619-1975

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
480 N MAIN ST STE 202
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALPHARETTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30009-8386
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-619-1974
Provider Business Practice Location Address Fax Number:
678-619-1975
Provider Enumeration Date:
06/05/2006

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: 207QG0300X , with the licence number:  25425 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207QG0300X , with the licence number: 71622 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 009932265 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1167568 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01-12861 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 202I085489 . This is a "MEDICARE PTAN" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 268099800 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 51538045 . This is a "BLUE CROSS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 01778200 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 51518001 . This is a "BLUE CROSS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 003148835A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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