Healthcare Provider Details

I. General information

NPI: 1932330305
Provider Name (Legal Business Name): SUSMITHA MARRI REDDY M B B S FRCR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2009
Last Update Date: 10/04/2022
Certification Date: 10/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4605 MACCORKLE AVE SW
SOUTH CHARLESTON WV
25309-1311
US

IV. Provider business mailing address

PO BOX 840
LIMA OH
45802-0840
US

V. Phone/Fax

Practice location:
  • Phone: 304-766-3600
  • Fax:
Mailing address:
  • Phone: 877-574-7116
  • Fax: 419-223-2726

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number241374
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number26976
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: