Provider Demographics
NPI:1841234929
Name:SWAMINATHAN, REVATHI (MD)
Entity Type:Individual
Prefix:
First Name:REVATHI
Middle Name:
Last Name:SWAMINATHAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 MAYO DR
Mailing Address - Street 2:
Mailing Address - City:GALESBURG
Mailing Address - State:IL
Mailing Address - Zip Code:61401-1211
Mailing Address - Country:US
Mailing Address - Phone:309-344-2831
Mailing Address - Fax:309-344-2014
Practice Address - Street 1:221 NE GLEN OAK AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61636-0001
Practice Address - Country:US
Practice Address - Phone:309-672-5700
Practice Address - Fax:309-671-2774
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2016-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360629912085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
RAILROAD MED PINOtherP00310337
IL036062991Medicaid
254642OtherHEALTHLINK
CM5868OtherRAILROAD MEDICARE
254642OtherHEALTHLINK
IL768730Medicare PIN
ILK24678Medicare ID - Type UnspecifiedMEDICARE