Provider Demographics
NPI:1083731939
Name:POREDDY, BHASKAR REDDY (PT)
Entity Type:Individual
Prefix:MR
First Name:BHASKAR REDDY
Middle Name:
Last Name:POREDDY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15051 DECKER CT
Mailing Address - Street 2:APT# 203
Mailing Address - City:GRAND HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49417-7952
Mailing Address - Country:US
Mailing Address - Phone:616-510-0034
Mailing Address - Fax:
Practice Address - Street 1:1615 S DESPELDER ST
Practice Address - Street 2:
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417-2633
Practice Address - Country:US
Practice Address - Phone:616-842-0770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501012194225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist