Provider Demographics
NPI:1013031533
Name:RAVEENA MEDICAL PC
Entity Type:Organization
Organization Name:RAVEENA MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TEEKARAM
Authorized Official - Middle Name:
Authorized Official - Last Name:PERSAUD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-806-1434
Mailing Address - Street 1:65-11 BOOTH STREET
Mailing Address - Street 2:SUITE 1C
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-4184
Mailing Address - Country:US
Mailing Address - Phone:718-806-1434
Mailing Address - Fax:718-806-1435
Practice Address - Street 1:1575 HILLSIDE AVENUE # 103
Practice Address - Street 2:SUITE #103
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11040-2501
Practice Address - Country:US
Practice Address - Phone:516-352-1804
Practice Address - Fax:516-352-1449
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY223596207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02728545Medicaid
NYI31217Medicare UPIN
NY02728545Medicaid