Basic Information
| Provider Information | |||||||||
| NPI: | 1013170646 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NALLU | ||||||||
| FirstName: | PRANITHA | ||||||||
| MiddleName: | REDDY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NALAMADA | ||||||||
| OtherFirstName: | PRANITHA | ||||||||
| OtherMiddleName: | REDDY | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 300 E MCBEE AVE FL 4 | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296012842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8645228603 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 14 RICHLAND MEDICAL PARK DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292036882 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032969200 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2008 | ||||||||
| LastUpdateDate: | 06/13/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2081P2900X | E-6621 | AR | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine | 2081P2900X | 37492 | SC | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine | 2081P2900X | N5272 | TX | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine | 174400000X | OH | N | Other Service Providers | Specialist | 208100000X | 37492 | SC | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 374927 | 05 | SC | MEDICAID |