Basic Information
| Provider Information | |||||||||
| NPI: | 1275577678 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REDDY | ||||||||
| FirstName: | RAJU | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4974 HIGBEE AVENUE | ||||||||
| Address2: | STE 209 | ||||||||
| City: | CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447182562 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304934553 | ||||||||
| FaxNumber: | 3304933762 | ||||||||
| Practice Location | |||||||||
| Address1: | 4974 HIGBEE AVENUE | ||||||||
| Address2: | STE 209 | ||||||||
| City: | CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447182562 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304934553 | ||||||||
| FaxNumber: | 3304933762 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2006 | ||||||||
| LastUpdateDate: | 03/05/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 35-043078 | OH | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 7610021 | 05 | OH | MEDICAID |