Provider Demographics
NPI:1427043843
Name:RAVEESH, CHICKAMAGALUR N (MD)
Entity Type:Individual
Prefix:DR
First Name:CHICKAMAGALUR
Middle Name:N
Last Name:RAVEESH
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 1:3409 LUDINGTON ST STE 203
Mailing Address - Street 2:
Mailing Address - City:ESCANABA
Mailing Address - State:MI
Mailing Address - Zip Code:49829-4213
Mailing Address - Country:US
Mailing Address - Phone:906-786-5707
Mailing Address - Fax:906-789-4446
Practice Address - Street 1:3409 LUDINGTON ST STE 203
Practice Address - Street 2:
Practice Address - City:ESCANABA
Practice Address - State:MI
Practice Address - Zip Code:49829-4213
Practice Address - Country:US
Practice Address - Phone:906-786-5707
Practice Address - Fax:906-789-4446
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2009-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301068941207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3286162Medicaid
MI381358036014OtherTRICARE
MI110127992OtherRAILROAD MEDICARE
G36899Medicare UPIN
MI0M30940002Medicare PIN