MEDICARE: DR. SRINIVASA REDDY VAKA MD

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	207R00000X	Internal Medicine Physician	E7137	AR
2	208M00000X	Hospitalist Physician	E7137	AR
3	207R00000X	Internal Medicine Physician	65117	MN

General Provider Information

NPI Number	:	1184863938
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SRINIVASA REDDY VAKA MD

Provider Business Mailing Address
First Line	:	FAIRVIEW CLINICS-BASS LAKE
Second Line	:	6320 WEDGWOOD RD N
City	:	MAPLE GROVE
State	:	MN
Zip	:	55311-3647
Country	:	US
Telephone Number	:	763-268-0400
Fax Number	:	763-268-0405

Provider Business Practice Location Address
First Line	:	FAIRVIEW CLINICS-BASS LAKE
Second Line	:	6320 WEDGWOOD RD N
City	:	MAPLE GROVE
State	:	MN
Zip	:	55311-3647
Country	:	US
Telephone Number	:	763-268-0400
Fax Number	:	763-268-0405

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

Provider Enumeration Date	:	02/17/2009
Last Update Date	:	09/23/2019

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