Provider Demographics
NPI:1225127848
Name:REDDY, RAJAMATHIAS Y (MD)
Entity Type:Individual
Prefix:
First Name:RAJAMATHIAS
Middle Name:Y
Last Name:REDDY
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 1:901 KIMOLE LN
Mailing Address - Street 2:STE B3
Mailing Address - City:ADRIAN
Mailing Address - State:MI
Mailing Address - Zip Code:49221-1491
Mailing Address - Country:US
Mailing Address - Phone:517-263-7337
Mailing Address - Fax:517-263-6150
Practice Address - Street 1:901 KIMOLE LN
Practice Address - Street 2:STE B3
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-1491
Practice Address - Country:US
Practice Address - Phone:517-263-7337
Practice Address - Fax:517-263-6150
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIRR066814208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI114183OtherCARE CHOICES PROVIDER #
MI3504600762OtherBCBS PROVIDER #
MI4125980Medicaid
MI03715OtherPARAMOUNT PROVIDER #
MIRR066814OtherLICENSE NUMBER
MI4125980Medicaid
MIRR066814OtherLICENSE NUMBER