Provider Demographics
NPI:1356360382
Name:CHENNAREDDY MD PC
Entity type:Organization
Organization Name:CHENNAREDDY MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:RAEFEAL
Authorized Official - Middle Name:NOAH
Authorized Official - Last Name:LUKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:646-883-0422
Mailing Address - Street 1:30 PURITAN AVE
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-6029
Mailing Address - Country:US
Mailing Address - Phone:718-250-8866
Mailing Address - Fax:718-250-6703
Practice Address - Street 1:10105 LEFFERTS BLVD STE 203
Practice Address - Street 2:
Practice Address - City:SOUTH RICHMOND HILL
Practice Address - State:NY
Practice Address - Zip Code:11419-2014
Practice Address - Country:US
Practice Address - Phone:718-441-8086
Practice Address - Fax:718-250-6036
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-19
Last Update Date:2024-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY112288207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00203118Medicaid
NY00203118Medicaid
NYW33602Medicare PIN
NY02949Medicare PIN