1447574678 NPI number — REDDY FAMILY MEDICAL CLINIC LLC

Table of content: (NPI 1447574678)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447574678 NPI number — REDDY FAMILY MEDICAL CLINIC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
REDDY FAMILY MEDICAL CLINIC LLC
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:
1447574678
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/17/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
217 RAILROAD AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DONALDSONVILLE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70346-2527
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
225-473-3931
Provider Business Mailing Address Fax Number:
225-473-3289

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
58725 BELLEVIEW DR
Provider Second Line Business Practice Location Address:
SWEET A-5
Provider Business Practice Location Address City Name:
PLAQUEMINE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70764-3948
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-687-6200
Provider Business Practice Location Address Fax Number:
225-687-6222
Provider Enumeration Date:
03/17/2010

Additional Information

Authorized Official

Authorized Official Last Name:
REDDY
Authorized Official First Name:
NAGARATNA
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
225-545-3631

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  05775R , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 5F973 . This is a "MEDICARE PART B" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".
  • Identifier: 1949809 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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