Provider Demographics
NPI:1508909128
Name:CHAKRADHAR C REDDY MD PC
Entity Type:Organization
Organization Name:CHAKRADHAR C REDDY MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PREMLATHA
Authorized Official - Middle Name:C
Authorized Official - Last Name:REDDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-791-5210
Mailing Address - Street 1:36232 GARFIELD RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48035-1128
Mailing Address - Country:US
Mailing Address - Phone:586-791-5210
Mailing Address - Fax:586-791-0049
Practice Address - Street 1:36232 GARFIELD RD
Practice Address - Street 2:
Practice Address - City:CLINTON TWP
Practice Address - State:MI
Practice Address - Zip Code:48035-1128
Practice Address - Country:US
Practice Address - Phone:586-791-5210
Practice Address - Fax:586-791-0049
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI034413174400000X
207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1508909128Medicaid
MI4301034413OtherPHYSICIAN LICENSE
MI0504271Medicare ID - Type Unspecified