Basic Information
| Provider Information | |||||||||
| NPI: | 1427184654 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | REDDY MEDICAL GROUP LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | REDDY PEDIATRICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 529 | ||||||||
| Address2: | |||||||||
| City: | ROYSTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 306620529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7066217575 | ||||||||
| FaxNumber: | 7066217557 | ||||||||
| Practice Location | |||||||||
| Address1: | 1061 DOWDY RD STE 101 | ||||||||
| Address2: | |||||||||
| City: | ATHENS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 306065700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7066217575 | ||||||||
| FaxNumber: | 7066217557 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2007 | ||||||||
| LastUpdateDate: | 05/17/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | REDDY | ||||||||
| AuthorizedOfficialFirstName: | RAM | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7062457371 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D | ||||||||
| NPICertificationDate: | 05/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 113885 | 01 | GA | PART A MEDICARE | OTHER |