Healthcare Provider Details

I. General information

NPI: 1235442732
Provider Name (Legal Business Name): PRITHAM P. REDDY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2010
Last Update Date: 07/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22250 PROVIDENCE DRIVE SUITE #555
SOUTHFIELD MI
48152
US

IV. Provider business mailing address

22250 PROVIDENCE DR SUITE 555
SOUTHFIELD MI
48075-4825
US

V. Phone/Fax

Practice location:
  • Phone: 248-424-5748
  • Fax: 248-443-1706
Mailing address:
  • Phone: 248-424-5748
  • Fax: 248-443-1706

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number4301075046
License Number StateMI

VIII. Authorized Official

Name: PRITHAM P. REDDY
Title or Position: PRESIDENT
Credential: MD
Phone: 248-424-5748