Provider Demographics
NPI:1023267945
Name:VLSR MADIREDDY MD PC
Entity type:Organization
Organization Name:VLSR MADIREDDY MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:SRINIVASA
Authorized Official - Middle Name:R
Authorized Official - Last Name:MADIREDDY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-214-1576
Mailing Address - Street 1:1715 HAMILTON DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48302-0222
Mailing Address - Country:US
Mailing Address - Phone:517-803-4544
Mailing Address - Fax:517-803-4509
Practice Address - Street 1:4129 OKEMOS RD
Practice Address - Street 2:STE 6
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-2822
Practice Address - Country:US
Practice Address - Phone:517-803-4544
Practice Address - Fax:517-803-4509
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-16
Last Update Date:2013-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301084372207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DO5269OtherRR MCR
MI10232267945Medicaid
MI0C30642OtherBCBSM
MI0C30644OtherBCBSM NPP GRP
MISM084372OtherSTATE LIC#
MI080F369400OtherBCBSM
MIMI1035 LOCALE 01Medicare PIN
MI0C30642OtherBCBSM