Provider Demographics
NPI:1811003247
Name:HEDDURSHETTI, RENUKA (MD)
Entity Type:Individual
Prefix:
First Name:RENUKA
Middle Name:
Last Name:HEDDURSHETTI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 MCCLINTOCK DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:BURR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60527-0871
Mailing Address - Country:US
Mailing Address - Phone:888-220-6432
Mailing Address - Fax:630-654-4253
Practice Address - Street 1:1854 W AUBURN RD
Practice Address - Street 2:SUITE 200
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48309-3868
Practice Address - Country:US
Practice Address - Phone:248-853-2323
Practice Address - Fax:248-853-8890
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2016-11-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301080813207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI499612510Medicaid
MIM73220027Medicare PIN
MIMI5695007Medicare PIN
MI499612510Medicaid