Provider Demographics
NPI:1225215569
Name:PEDDIREDDY, SAILAJA (MD)
Entity Type:Individual
Prefix:
First Name:SAILAJA
Middle Name:
Last Name:PEDDIREDDY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23077 GREENFIELD RD
Mailing Address - Street 2:SUITE 240
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-3709
Mailing Address - Country:US
Mailing Address - Phone:248-809-6402
Mailing Address - Fax:248-809-6417
Practice Address - Street 1:23077 GREENFIELD RD
Practice Address - Street 2:SUITE 240
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-3709
Practice Address - Country:US
Practice Address - Phone:248-809-6402
Practice Address - Fax:248-809-6417
Is Sole Proprietor?:No
Enumeration Date:2008-01-29
Last Update Date:2013-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI#4301075965207R00000X
MI4301075965207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI20-5485614OtherTAX ID
MISP075965OtherLICENS
MI110F336360OtherBCBSM
MI20-5485614OtherTAX ID