Provider Demographics
NPI:1881654424
Name:RAVIKRISHNAN, K P (MD)
Entity Type:Individual
Prefix:
First Name:K
Middle Name:P
Last Name:RAVIKRISHNAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:KOREMBETH
Other - Middle Name:P
Other - Last Name:RAVIKRISHNAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:130 TOWN CENTER DRIVE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-1744
Mailing Address - Country:US
Mailing Address - Phone:248-585-8221
Mailing Address - Fax:248-585-8270
Practice Address - Street 1:3535 W 13 MILE RD
Practice Address - Street 2:STE. 507
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-6710
Practice Address - Country:US
Practice Address - Phone:248-551-0497
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2017-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301032933207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI290F361080OtherBCBSM
MI1566256Medicaid
MI1566256Medicaid
MI0F31234007Medicare ID - Type Unspecified