Basic Information
| Provider Information | |||||||||
| NPI: | 1255313466 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KAMIREDDI | ||||||||
| FirstName: | MADHAVI | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | REDDY | ||||||||
| OtherFirstName: | MADHAVI | ||||||||
| OtherMiddleName: | A | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 289 GREAT ROAD | ||||||||
| Address2: | SUITE G1 | ||||||||
| City: | ACTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9786791200 | ||||||||
| FaxNumber: | 9784864037 | ||||||||
| Practice Location | |||||||||
| Address1: | 289 GREAT ROAD | ||||||||
| Address2: | SUITE G1 | ||||||||
| City: | ACTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9786791200 | ||||||||
| FaxNumber: | 9784864037 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2005 | ||||||||
| LastUpdateDate: | 01/09/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 223251 | MA | N | Behavioral Health & Social Service Providers | Counselor | 101YM0800X | 223251 | MA | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 2084P0800X | 223251 | MA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 043476807-17 | 01 | MA | PACIFICARE | OTHER | 363646 | 01 | MA | MHN | OTHER | 494182 | 01 | MA | TUFTS | OTHER | 2105462 | 05 | MA | MEDICAID | 01Y008389MA01 | 01 | NH | BCBSNH | OTHER | 967628 | 01 | MA | NETWORK HEALTH | OTHER | J28990 | 01 | MA | BCBSMA | OTHER | 800708000 | 01 | MA | MAGELLAN | OTHER |