Provider Demographics
NPI:1225082654
Name:LINGAREDDY DEVIREDDY MD PC
Entity Type:Organization
Organization Name:LINGAREDDY DEVIREDDY MD PC
Other - Org Name:CARDIOVASCULAR PHYSICIAN PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:LINGAREDDY
Authorized Official - Middle Name:
Authorized Official - Last Name:DEVIREDDY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-574-0890
Mailing Address - Street 1:11900 E 12 MILE RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-3487
Mailing Address - Country:US
Mailing Address - Phone:586-574-0890
Mailing Address - Fax:586-574-9321
Practice Address - Street 1:11900 E 12 MILE RD
Practice Address - Street 2:SUITE 103
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-3487
Practice Address - Country:US
Practice Address - Phone:586-574-0890
Practice Address - Fax:586-574-0890
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2010-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301032513207RC0000X
MI4301080674207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0N70490Medicare ID - Type Unspecified