Healthcare Provider Details

I. General information

NPI: 1720005358
Provider Name (Legal Business Name): KAVITHA REDDY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 04/08/2024
Certification Date: 04/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

915 N GRAND BLVD
SAINT LOUIS MO
63106-1621
US

IV. Provider business mailing address

75 REMITT DRIVE LOCKBOX 3274
CHICAGO IL
60675-3274
US

V. Phone/Fax

Practice location:
  • Phone: 314-652-4100
  • Fax:
Mailing address:
  • Phone: 866-916-5259
  • Fax: 231-922-4030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036-108796
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: