Provider Demographics
NPI:1346294469
Name:RAVANAM, SRINIVAS R (MD)
Entity Type:Individual
Prefix:
First Name:SRINIVAS
Middle Name:R
Last Name:RAVANAM
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 1:455 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EAST DUNDEE
Mailing Address - State:IL
Mailing Address - Zip Code:60118-1529
Mailing Address - Country:US
Mailing Address - Phone:847-428-2273
Mailing Address - Fax:847-428-3128
Practice Address - Street 1:455 E MAIN ST
Practice Address - Street 2:
Practice Address - City:EAST DUNDEE
Practice Address - State:IL
Practice Address - Zip Code:60118-1529
Practice Address - Country:US
Practice Address - Phone:847-428-2273
Practice Address - Fax:847-428-3128
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2014-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036110141207U00000X, 207R00000X, 2083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI46940020OtherSTATE LICENSE
IL036110141Medicaid
ILI47280Medicare UPIN
ILK53588Medicare PIN