Healthcare Provider Details

I. General information

NPI: 1386645299
Provider Name (Legal Business Name): BASIVI REDDY BADDIGAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2005
Last Update Date: 02/10/2021
Certification Date: 02/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43211 DALCOMA DR STE. 3
CLINTON TWP MI
48038-6309
US

IV. Provider business mailing address

PO BOX 7002
BLOOMFIELD MI
48302-7002
US

V. Phone/Fax

Practice location:
  • Phone: 586-263-6812
  • Fax: 586-263-6835
Mailing address:
  • Phone: 586-466-9718
  • Fax: 586-466-9961

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number4301053679
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number4301053679
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: