Basic Information
| Provider Information | |||||||||
| NPI: | 1659329084 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REDDY | ||||||||
| FirstName: | PAVAN | ||||||||
| MiddleName: | GARLAPATY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14500 NORTHLINE RD | ||||||||
| Address2: | |||||||||
| City: | SOUTHGATE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481952402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342814197 | ||||||||
| FaxNumber: | 7342820093 | ||||||||
| Practice Location | |||||||||
| Address1: | 14500 NORTHLINE RD | ||||||||
| Address2: | |||||||||
| City: | SOUTHGATE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481952402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342814197 | ||||||||
| FaxNumber: | 7342820093 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2006 | ||||||||
| LastUpdateDate: | 12/13/2018 | ||||||||
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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 | 207Y00000X | 4301063732 | MI | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 0408279532 | 01 | MI | BL;UE CROSS PIN # | OTHER |