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General NPI Number Information
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NPI Number | 1669454559
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Entity Type | Organization
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Legal Business Name | ENDOCRINOLOGY AND DIABETES CENTER OF PORT HURON PLLC
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Dates
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Enumeration Date | 11/16/2005
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Last Update Date | 11/10/2009
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Provider Practice Location Address
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Address Line | 4190 24TH AVE SUITE: 201
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City | FORT GRATIOT
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State | MI
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Zip | 48059-3882
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Country | US
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Telephone | 810-989-7478
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Fax | 810-989-7644
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Provider Business Mailing Address
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Address Line | 4190 24TH AVE SUITE: 201
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City | FORT GRATIOT
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State | MI
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Zip | 48059-3882
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Country | US
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Telephone | 810-989-7478
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Fax | 810-989-7644
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Authorized Official
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Title or Position | GENERAL PARTNER
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Name | SUSHMA REDDY
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Credential | MD
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Telephone | 810-989-7478
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RE0101X
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Taxonomy Name | Endocrinology, Diabetes & Metabolism Physician
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License Number |
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License Number State |
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