Provider Demographics
NPI:1669454559
Name:ENDOCRINOLOGY AND DIABETES CENTER OF PORT HURON PLLC
Entity Type:Organization
Organization Name:ENDOCRINOLOGY AND DIABETES CENTER OF PORT HURON PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:SUSHMA
Authorized Official - Middle Name:
Authorized Official - Last Name:REDDY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:810-989-7478
Mailing Address - Street 1:4190 24TH AVE
Mailing Address - Street 2:SUITE: 201
Mailing Address - City:FORT GRATIOT
Mailing Address - State:MI
Mailing Address - Zip Code:48059-3882
Mailing Address - Country:US
Mailing Address - Phone:810-989-7478
Mailing Address - Fax:810-989-7644
Practice Address - Street 1:4190 24TH AVE
Practice Address - Street 2:SUITE: 201
Practice Address - City:FORT GRATIOT
Practice Address - State:MI
Practice Address - Zip Code:48059-3882
Practice Address - Country:US
Practice Address - Phone:810-989-7478
Practice Address - Fax:810-989-7644
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-16
Last Update Date:2009-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty