Provider Demographics
NPI:1033313069
Name:MADIREDDY, SRINIVASA REDDY (MD)
Entity Type:Individual
Prefix:
First Name:SRINIVASA
Middle Name:REDDY
Last Name:MADIREDDY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1715 HAMILTON DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48302-0222
Mailing Address - Country:US
Mailing Address - Phone:517-803-4544
Mailing Address - Fax:517-803-4509
Practice Address - Street 1:4129 OKEMOS RD
Practice Address - Street 2:STE 6
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-2822
Practice Address - Country:US
Practice Address - Phone:517-803-4544
Practice Address - Fax:517-803-4509
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2009-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301084372207QG0300X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MISM084372OtherSTATE LIC#
MI0803314742OtherBCBSM
MI70-0-F32947-0OtherBCBS CPIN #
MIMI1035001Medicare PIN