Provider Demographics
NPI:1932108511
Name:KANAKAMEDALA, RAVI (MD)
Entity Type:Individual
Prefix:
First Name:RAVI
Middle Name:
Last Name:KANAKAMEDALA
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 1:8840 CALUMET AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-2545
Mailing Address - Country:US
Mailing Address - Phone:219-836-7246
Mailing Address - Fax:219-836-6454
Practice Address - Street 1:8840 CALUMET AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-2529
Practice Address - Country:US
Practice Address - Phone:219-836-7246
Practice Address - Fax:219-836-6454
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01035342A208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01035342AOtherBCBS OF IL
GA050085655OtherMEDICARE RAILROAD
IN5841131OtherAETNA
IN000000330862OtherBLUE CROSS BLUE SHEILD
IN01035342AOtherLICENSE NUMBER
IN100259430AMedicaid
IN01035342AOtherLICENSE NUMBER
IN100259430AMedicaid