MEDICARE: SASIKALA SANNAPAREDDY M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	226752	MA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	J29983	OTHER	MA	BLUE CROSS/BLUE SHIELD

General Provider Information

NPI Number	:	1104870781
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SASIKALA SANNAPAREDDY M.D.

Provider Business Mailing Address
First Line	:	63 MAIN ST
Second Line	:
City	:	BROCKTON
State	:	MA
Zip	:	02301-4342
Country	:	US
Telephone Number	:	508-559-1567
Fax Number	:	508-559-5073

Provider Business Practice Location Address
First Line	:	63 MAIN ST
Second Line	:
City	:	BROCKTON
State	:	MA
Zip	:	02301-4012
Country	:	US
Telephone Number	:	508-559-6699
Fax Number	:	508-583-4649

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/19/2006
Last Update Date	:	06/11/2010

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