Healthcare Provider Details

I. General information

NPI: 1760808109
Provider Name (Legal Business Name): RAVEENA REDDY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2014
Last Update Date: 09/14/2021
Certification Date: 09/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST
JACKSON MS
39216-4500
US

IV. Provider business mailing address

5665 PEACHTREE DUNWOODY RD
ATLANTA GA
30342-1764
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-1540
  • Fax:
Mailing address:
  • Phone: 678-843-7001
  • Fax: 419-866-5453

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZC0006X
TaxonomyClinical Pathology Physician
License Number783L
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number74333
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number37720
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: