MEDICARE: ENDOCRINOLOGY AND DIABETES CENTER OF PORT HURON PLLC

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	207RE0101X	Endocrinology, Diabetes & Metabolism Physician

General Provider Information

NPI Number	:	1669454559
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ENDOCRINOLOGY AND DIABETES CENTER OF PORT HURON PLLC

Provider Business Mailing Address
First Line	:	4190 24TH AVE
Second Line	:	SUITE: 201
City	:	FORT GRATIOT
State	:	MI
Zip	:	48059-3882
Country	:	US
Telephone Number	:	810-989-7478
Fax Number	:	810-989-7644

Provider Business Practice Location Address
First Line	:	4190 24TH AVE
Second Line	:	SUITE: 201
City	:	FORT GRATIOT
State	:	MI
Zip	:	48059-3882
Country	:	US
Telephone Number	:	810-989-7478
Fax Number	:	810-989-7644

Authorized Official
Title or Position	:	GENERAL PARTNER
Name	:	SUSHMA REDDY
Credential	:	MD
Telephone Number	:	810-989-7478

Provider Enumeration Date	:	11/16/2005
Last Update Date	:	11/10/2009

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