Provider Demographics
NPI:1417236076
Name:REDDY, YARATHA KEDARNATH
Entity Type:Individual
Prefix:
First Name:YARATHA
Middle Name:KEDARNATH
Last Name:REDDY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:380 HOSPITAL DR
Mailing Address - Street 2:SUITE 410
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31217-8001
Mailing Address - Country:US
Mailing Address - Phone:478-972-2558
Mailing Address - Fax:
Practice Address - Street 1:380 HOSPITAL DR
Practice Address - Street 2:SUITE 410
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31217-8001
Practice Address - Country:US
Practice Address - Phone:478-972-2558
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-12
Last Update Date:2013-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA367H00000X
GA006218367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA580628385OtherTRICARE
GA003112654CMedicaid
GA003112654BMedicaid
GA625700OtherWELLCARE
GAP01003634OtherRAILROAD MEDICARE
GA003112654AMedicaid
GA003112654DMedicaid
GA003112654DMedicaid