Provider Demographics
NPI:1235363581
Name:REDDY, SWAROOP M (MD)
Entity Type:Individual
Prefix:
First Name:SWAROOP
Middle Name:M
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:PO BOX 745
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30459-0745
Mailing Address - Country:US
Mailing Address - Phone:912-764-6906
Mailing Address - Fax:912-764-3252
Practice Address - Street 1:5 W ALTMAN ST
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-5212
Practice Address - Country:US
Practice Address - Phone:912-764-6906
Practice Address - Fax:912-764-3252
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-14
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA029292208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000373997AMedicaid
1808541OtherCIGNA
GA479327OtherBCBS
GA37BBDWXMedicare PIN
GA479327OtherBCBS
1808541OtherCIGNA