Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QG0300X | Family Doctor - Geriatric Medicine | 4301084372 | MI |
NPI | 1033313069 |
---|---|
Provider Name | Srinivasa Reddy Madireddy |
First Address | Bloomfield, MI 48302-0222 |
Second Address | Okemos, MI 48864-2822 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/06/2007 |
Last Update Date | 02/12/2009 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0803314742 | BCBSM (01) | MI |
70-0-F32947-0 | BCBS CPIN # (01) | MI |
SM084372 | STATE LIC# (01) | MI |