Provider Demographics
NPI:1154309292
Name:PATHI, JANNA REDDY (MD)
Entity Type:Individual
Prefix:MR
First Name:JANNA
Middle Name:REDDY
Last Name:PATHI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 148
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:KY
Mailing Address - Zip Code:42347-0148
Mailing Address - Country:US
Mailing Address - Phone:270-298-5417
Mailing Address - Fax:270-298-5285
Practice Address - Street 1:1201 PINE ST
Practice Address - Street 2:
Practice Address - City:ELDORADO
Practice Address - State:IL
Practice Address - Zip Code:62930-1634
Practice Address - Country:US
Practice Address - Phone:618-273-3361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.140240208600000X
KY31000208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1065454OtherPASSPORT
KY64310006Medicaid
000000042142OtherBCBS
KY000000538224OtherANTHEM
KY020025142OtherRAILROAD MEDICARE
000000042142OtherBCBS
KY000000538224OtherANTHEM
KY00443001Medicare PIN
KY64310006Medicaid