MEDICARE: PROFESSIONAL PRIMARY CARE SERVICES PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	4301068131	MI

General Provider Information

NPI Number	:	1588852933
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROFESSIONAL PRIMARY CARE SERVICES PC

Provider Business Mailing Address
First Line	:	PO BOX 7752
Second Line	:
City	:	BLOOMFIELD HILLS
State	:	MI
Zip	:	48302-7752
Country	:	US
Telephone Number	:	248-396-6667
Fax Number	:

Provider Business Practice Location Address
First Line	:	43996 WOODWARD AVE STE 104
Second Line	:
City	:	BLOOMFIELD HILLS
State	:	MI
Zip	:	48302-5028
Country	:	US
Telephone Number	:	248-977-4138
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JAYAKAR REDDY KANMANTHA REDDY
Credential	:	M.D.
Telephone Number	:	248-396-6667

Provider Enumeration Date	:	10/11/2007
Last Update Date	:	07/11/2011

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