Healthcare Provider Details

I. General information

NPI: 1265847396
Provider Name (Legal Business Name): MADHAVI REDDY CHERUKULA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2014
Last Update Date: 03/25/2022
Certification Date: 03/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 S HERITAGE WOODS DR
APPLETON WI
54915-1408
US

IV. Provider business mailing address

3 NEENAH CTR
NEENAH WI
54956-3070
US

V. Phone/Fax

Practice location:
  • Phone: 920-225-7875
  • Fax:
Mailing address:
  • Phone: 920-228-7875
  • Fax: 920-993-5003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number30174
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number30174
License Number StateNE
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberMD-47285
License Number StateIA
# 4
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number76645
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: