Provider Demographics
NPI:1790981322
Name:REDDY, MAHENDRANATH (MD)
Entity Type:Individual
Prefix:
First Name:MAHENDRANATH
Middle Name:
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 1:2799 W. GRAND BLVD
Mailing Address - Street 2:HENRY FORD HOSPITAL, CFP-5 DEPT OF NEPHROLOGY,
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202
Mailing Address - Country:US
Mailing Address - Phone:313-916-2710
Mailing Address - Fax:
Practice Address - Street 1:27211 LAHSER RD
Practice Address - Street 2:SUITE # 200
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-8469
Practice Address - Country:US
Practice Address - Phone:248-358-4892
Practice Address - Fax:248-358-5125
Is Sole Proprietor?:No
Enumeration Date:2007-06-21
Last Update Date:2012-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMR084085207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI205485614OtherTAX ID
MI110F336360OtherBCBSM
MI1346398971OtherGROUP NPI
MI207R00000XOtherTAXONOMY
MI4301084085OtherLICENSE
MI0P41360027Medicare PIN