Provider Demographics
NPI:1598067522
Name:BABIREDDY, PHANIVARDHAN REDDY (MD)
Entity Type:Individual
Prefix:
First Name:PHANIVARDHAN
Middle Name:REDDY
Last Name:BABIREDDY
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 1:210 N KENILWORTH AVE APT 9
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-2062
Mailing Address - Country:US
Mailing Address - Phone:502-460-3440
Mailing Address - Fax:
Practice Address - Street 1:1111 SUPERIOR ST
Practice Address - Street 2:101
Practice Address - City:MELROSE PARK
Practice Address - State:IL
Practice Address - Zip Code:60160-4138
Practice Address - Country:US
Practice Address - Phone:708-344-2161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-23
Last Update Date:2010-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.055722207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine