Provider Demographics
NPI:1629048962
Name:RAGHAVENDRA, MEDA (MD)
Entity Type:Individual
Prefix:
First Name:MEDA
Middle Name:
Last Name:RAGHAVENDRA
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 1:2160 S FIRST AVE
Mailing Address - Street 2:(15750 MARIAN DR., HOMER GLEN, IL. 60526)
Mailing Address - City:MAYWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60153
Mailing Address - Country:US
Mailing Address - Phone:708-216-6462
Mailing Address - Fax:708-216-1249
Practice Address - Street 1:2160 S FIRST AVE
Practice Address - Street 2:(15750 MARIAN DR., HOMER GLEN, IL. 60526)
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153
Practice Address - Country:US
Practice Address - Phone:708-216-6462
Practice Address - Fax:708-216-1249
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2010-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36092881208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL98571Medicare ID - Type Unspecified
IL590760Medicare ID - Type Unspecified
H22290Medicare UPIN