Healthcare Provider Details

I. General information

NPI: 1619143807
Provider Name (Legal Business Name): PAVAN G REDDY MD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2008
Last Update Date: 05/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14500 NORTHLINE RD
SOUTHGATE MI
48195-2402
US

IV. Provider business mailing address

14500 NORTHLINE RD
SOUTHGATE MI
48195-2402
US

V. Phone/Fax

Practice location:
  • Phone: 734-281-4197
  • Fax: 734-282-0093
Mailing address:
  • Phone: 734-281-4197
  • Fax: 734-282-0093

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number4301063732
License Number StateMI

VIII. Authorized Official

Name: DR. PAVAN G REDDY
Title or Position: OWNER
Credential: MD
Phone: 734-281-4197