Provider Demographics
NPI:1568468346
Name:RAVINDRANATHAN, MANNIL (MD)
Entity Type:Individual
Prefix:DR
First Name:MANNIL
Middle Name:
Last Name:RAVINDRANATHAN
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 1:1505.N.SMITH
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959
Mailing Address - Country:US
Mailing Address - Phone:618-993-2413
Mailing Address - Fax:618-997-1901
Practice Address - Street 1:1008 W CHERRY ST
Practice Address - Street 2:STE D
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-1998
Practice Address - Country:US
Practice Address - Phone:618-997-2396
Practice Address - Fax:618-997-1901
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-25
Last Update Date:2013-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL3648567207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC38123Medicare UPIN
IL236020Medicare ID - Type Unspecified