1710986302 NPI number — BAL T REDDY MD

Table of content: BAL T REDDY MD (NPI 1710986302)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710986302 NPI number — BAL T REDDY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
REDDY
Provider First Name:
BAL
Provider Middle Name:
T
Provider Name Prefix Text:
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:
1710986302
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/26/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1100 MCCULLOUGH AVE
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78212-4813
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-271-3204
Provider Business Mailing Address Fax Number:
210-222-2761

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
94 BRIGGS ST
Provider Second Line Business Practice Location Address:
SUITE 600
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78224-1221
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-923-7736
Provider Business Practice Location Address Fax Number:
210-923-7100
Provider Enumeration Date:
07/18/2005

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: 207RC0000X , with the licence number:  G6601 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 84856G . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 060047791 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 136714612 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00948217 . This is a "RAILROAD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 8CU333 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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