Provider Demographics
NPI:1376504027
Name:RAVI, CHAITANYA KUMAR (MD)
Entity Type:Individual
Prefix:DR
First Name:CHAITANYA
Middle Name:KUMAR
Last Name:RAVI
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 1:5401 OLD COURT RD
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:RANDALLSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21133-5103
Mailing Address - Country:US
Mailing Address - Phone:410-601-5524
Mailing Address - Fax:410-601-8946
Practice Address - Street 1:5401 OLD COURT RD
Practice Address - Street 2:
Practice Address - City:RANDALLSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21133-5103
Practice Address - Country:US
Practice Address - Phone:410-521-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD37333207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDP00309485OtherR/R MEDICARE PROVIDER #
MDCA8374OtherR/R MEDICARE GROUP #
MD110167459OtherR/R MEDICARE PROVIDER #
MD594321300Medicaid
MDCN6601OtherR/R MEDICARE GROUP #
MDS589L814Medicare PIN
MD110167459OtherR/R MEDICARE PROVIDER #
MDCN6601OtherR/R MEDICARE GROUP #
MDKL19040WMedicare PIN
MDE38230Medicare UPIN