Healthcare Provider Details

I. General information

NPI: 1649223447
Provider Name (Legal Business Name): RAMESH REDDY KEESARA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 03/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

187 W MAIN ST
DECATURVILLE TN
38329
US

IV. Provider business mailing address

187 W MAIN ST PO BOX 127
DECATURVILLE TN
38329
US

V. Phone/Fax

Practice location:
  • Phone: 731-852-2761
  • Fax: 731-852-2781
Mailing address:
  • Phone: 731-852-2761
  • Fax: 731-852-2781

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number12891
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: