Healthcare Provider Details

I. General information

NPI: 1225215569
Provider Name (Legal Business Name): SAILAJA PEDDIREDDY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2008
Last Update Date: 12/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23077 GREENFIELD RD SUITE 240
SOUTHFIELD MI
48075-3709
US

IV. Provider business mailing address

23077 GREENFIELD RD SUITE 240
SOUTHFIELD MI
48075-3709
US

V. Phone/Fax

Practice location:
  • Phone: 248-809-6402
  • Fax: 248-809-6417
Mailing address:
  • Phone: 248-809-6402
  • Fax: 248-809-6417

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number#4301075965
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number4301075965
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: