Provider Demographics
NPI:1154433340
Name:MADIREDDY SUBBAREDDY MD PC
Entity type:Organization
Organization Name:MADIREDDY SUBBAREDDY MD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MADIREDDY
Authorized Official - Middle Name:
Authorized Official - Last Name:SUBAREDDY
Authorized Official - Suffix:
Authorized Official - Credentials:MD PC
Authorized Official - Phone:516-724-6309
Mailing Address - Street 1:145 ST NICHOLAS AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11237-4006
Mailing Address - Country:US
Mailing Address - Phone:718-353-5856
Mailing Address - Fax:718-670-6479
Practice Address - Street 1:14015 SANFORD AVE
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355
Practice Address - Country:US
Practice Address - Phone:718-353-5856
Practice Address - Fax:718-870-6479
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY112106208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00202584Medicaid
NY00202584Medicaid
NY626882Medicare ID - Type Unspecified