=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548487572
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MALLADI S REDDY, MD, FACC, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/19/2007
-----------------------------------------------------
Last Update Date | 09/05/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4201 GARTH RD SUITE 315
-----------------------------------------------------
City | BAYTOWN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77521-3167
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-420-6000
-----------------------------------------------------
Fax | 281-420-9000
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4201 GARTH RD SUITE 315
-----------------------------------------------------
City | BAYTOWN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77521-3167
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-420-6000
-----------------------------------------------------
Fax | 281-420-9000
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DOCTOR OF MEDICINE
-----------------------------------------------------
Name | DR. MALLADI S REDDY
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 281-420-6000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | J3885
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------