Healthcare Provider Details

I. General information

NPI: 1649384892
Provider Name (Legal Business Name): PRADEEP GOPALA REDDY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2006
Last Update Date: 06/08/2021
Certification Date: 06/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3412 OFFICE PARK DRIVE
MARION IL
62959-1998
US

IV. Provider business mailing address

3412 OFFICE PARK DRIVE
MARION IL
62959-1998
US

V. Phone/Fax

Practice location:
  • Phone: 618-993-0404
  • Fax: 618-993-1717
Mailing address:
  • Phone: 618-993-0404
  • Fax: 618-993-1717

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036110081
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number036110081
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: