Provider Demographics
NPI:1376517359
Name:POLASANI, RAVINDER R (MD)
Entity Type:Individual
Prefix:
First Name:RAVINDER
Middle Name:R
Last Name:POLASANI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49 S CASS ST
Mailing Address - Street 2:SUITE 1B
Mailing Address - City:BATTLE CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:49017-2331
Mailing Address - Country:US
Mailing Address - Phone:269-969-8920
Mailing Address - Fax:269-969-8921
Practice Address - Street 1:833 LAURENCE AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49202-2981
Practice Address - Country:US
Practice Address - Phone:517-782-1700
Practice Address - Fax:517-787-9512
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2015-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIRP073528207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104078155Medicaid
MIP14130003Medicare ID - Type Unspecified
MIG40082Medicare UPIN