Provider Demographics
NPI:1396777405
Name:REDDY, ILLURI RADHIKA (MD)
Entity type:Individual
Prefix:
First Name:ILLURI
Middle Name:RADHIKA
Last Name:REDDY
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:PO BOX 5576
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37602-5576
Mailing Address - Country:US
Mailing Address - Phone:423-926-6266
Mailing Address - Fax:423-926-7599
Practice Address - Street 1:101 MED TECH PKWY
Practice Address - Street 2:SUITE 305
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-4007
Practice Address - Country:US
Practice Address - Phone:423-926-6266
Practice Address - Fax:423-926-7599
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2011-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN25510207P00000X
TNMD25510207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3081801Medicaid
KY64918873Medicaid
VA1396777405Medicaid
TN3081807Medicaid
930094971OtherRAILROAD MEDICARE
VA1396777405Medicaid
TN3081801Medicaid
F76542Medicare UPIN