Provider Demographics
NPI:1114155124
Name:RAVI YADAVA, D.O. PC
Entity Type:Organization
Organization Name:RAVI YADAVA, D.O. PC
Other - Org Name:PERFORMANCE REHABILITATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:RAVI
Authorized Official - Middle Name:
Authorized Official - Last Name:YADAVA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:314-994-9355
Mailing Address - Street 1:675 OLD BALLAS RD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-7083
Mailing Address - Country:US
Mailing Address - Phone:314-994-9355
Mailing Address - Fax:314-994-0796
Practice Address - Street 1:675 OLD BALLAS RD
Practice Address - Street 2:SUITE 210
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-7083
Practice Address - Country:US
Practice Address - Phone:314-994-9355
Practice Address - Fax:314-994-0796
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-29
Last Update Date:2009-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO104036208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOG48540Medicare UPIN