Provider Demographics
NPI:1083730907
Name:MADALA, RAVICHAND (MD)
Entity Type:Individual
Prefix:DR
First Name:RAVICHAND
Middle Name:
Last Name:MADALA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:RAVICHAND
Other - Middle Name:
Other - Last Name:MADALA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC845
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:616-486-6557
Mailing Address - Fax:616-486-6702
Practice Address - Street 1:4100 LAKE DR SE STE 200
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-8292
Practice Address - Country:US
Practice Address - Phone:616-391-3759
Practice Address - Fax:616-391-3052
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.089399207R00000X
OH350893992084N0400X
MI4301102594207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIM74460906Medicare PIN
MIM74460906Medicare PIN
OH3147900Medicaid