MEDICARE: CHAITANYA DEEPTHI KEDARISETTI PT

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	225100000X	Physical Therapist	5501014995	MI

General Provider Information

NPI Number	:	1477878429
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHAITANYA DEEPTHI KEDARISETTI PT

Provider Business Mailing Address
First Line	:	2213 S LOVINGTON DR
Second Line	:	APT 107
City	:	TROY
State	:	MI
Zip	:	48083-4370
Country	:	US
Telephone Number	:	419-819-7314
Fax Number	:

Provider Business Practice Location Address
First Line	:	5428 METROPOLITAN PKWY
Second Line	:
City	:	STERLING HEIGHTS
State	:	MI
Zip	:	48310-4103
Country	:	US
Telephone Number	:	586-977-0001
Fax Number	:

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

Provider Enumeration Date	:	04/02/2010
Last Update Date	:	04/02/2010

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