Provider Demographics
NPI:1386846160
Name:PENNVIEW MEDICAL CLINIC,INC.
Entity Type:Organization
Organization Name:PENNVIEW MEDICAL CLINIC,INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ASHWIN
Authorized Official - Middle Name:N
Authorized Official - Last Name:RAVAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:734-285-5280
Mailing Address - Street 1:12611 PENNSYLVANIA RD
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:MI
Mailing Address - Zip Code:48193-4224
Mailing Address - Country:US
Mailing Address - Phone:734-285-5280
Mailing Address - Fax:734-285-6730
Practice Address - Street 1:12611 PENNSYLVANIA RD
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:MI
Practice Address - Zip Code:48193-4224
Practice Address - Country:US
Practice Address - Phone:734-285-5280
Practice Address - Fax:734-285-6730
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI035652305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIF05616Medicare UPIN