Healthcare Provider Details

I. General information

NPI: 1245263524
Provider Name (Legal Business Name): SURENDER REDDY EDLA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 09/03/2021
Certification Date: 09/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1790 OLD TRAIL RD
ETTERS PA
17319-9652
US

IV. Provider business mailing address

6020 RICHMOND HWY STE 102
ALEXANDRIA VA
22303-2157
US

V. Phone/Fax

Practice location:
  • Phone: 717-938-6588
  • Fax: 717-938-9601
Mailing address:
  • Phone: 443-363-3953
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101239065
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD429426
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: