Provider Demographics
NPI:1740237775
Name:HANUMAIAH, RAVINDRA (MD)
Entity Type:Individual
Prefix:
First Name:RAVINDRA
Middle Name:
Last Name:HANUMAIAH
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:PO BOX 19070
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54307-9070
Mailing Address - Country:US
Mailing Address - Phone:920-496-4700
Mailing Address - Fax:
Practice Address - Street 1:835 S VAN BUREN ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3526
Practice Address - Country:US
Practice Address - Phone:920-496-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI48283-20208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34826200Medicaid
WI48283OtherWI STATE LICENSE
P00352118Medicare PIN
DE1721Medicare PIN