Provider Demographics
NPI:1518123298
Name:REDDY, SIREEN THEGALAPALLE (MD)
Entity Type:Individual
Prefix:DR
First Name:SIREEN
Middle Name:THEGALAPALLE
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 905
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49204-0905
Mailing Address - Country:US
Mailing Address - Phone:517-783-2612
Mailing Address - Fax:517-783-5991
Practice Address - Street 1:205 N EAST AVE
Practice Address - Street 2:IMAGING SERVICES
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1753
Practice Address - Country:US
Practice Address - Phone:517-783-2612
Practice Address - Fax:517-783-5991
Is Sole Proprietor?:No
Enumeration Date:2008-08-01
Last Update Date:2019-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43011064382085R0204X, 2085R0202X
TXP12142085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-117273Other036-117273
MI4301106438OtherMICHIGAN MEDICAL LICENSE
MI4301106438OtherMICHIGAN MEDICAL LICENSE