Basic Information
| Provider Information | |||||||||
| NPI: | 1760808109 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REDDY | ||||||||
| FirstName: | RAVEENA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5665 PEACHTREE DUNWOODY RD | ||||||||
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| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303421764 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6788437001 | ||||||||
| FaxNumber: | 4198665453 | ||||||||
| Practice Location | |||||||||
| Address1: | 2500 N STATE ST | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392164500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019841540 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2014 | ||||||||
| LastUpdateDate: | 09/14/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZC0006X | 783L | MS | N | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology | 207ZP0102X | 74333 | GA | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZP0102X | 37720 | SC | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
No ID Information.