Provider Demographics
NPI:1184654154
Name:THABOLINGAM, RAVEEND C (MD)
Entity Type:Individual
Prefix:
First Name:RAVEEND
Middle Name:C
Last Name:THABOLINGAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18161 W 12 MILE RD STE 2
Mailing Address - Street 2:
Mailing Address - City:LATHRUP VILLAGE
Mailing Address - State:MI
Mailing Address - Zip Code:48076-2662
Mailing Address - Country:US
Mailing Address - Phone:248-552-1200
Mailing Address - Fax:
Practice Address - Street 1:18161 W 12 MILE RD STE 2
Practice Address - Street 2:
Practice Address - City:LATHRUP VILLAGE
Practice Address - State:MI
Practice Address - Zip Code:48076-2662
Practice Address - Country:US
Practice Address - Phone:248-552-1200
Practice Address - Fax:248-552-1200
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2017-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301080781207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4889152/10Medicaid
I54929Medicare UPIN
MI4889152/10Medicaid