Provider Demographics
NPI:1972610491
Name:RAVAEE, MANOUCHER (MD)
Entity Type:Individual
Prefix:
First Name:MANOUCHER
Middle Name:
Last Name:RAVAEE
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 1:733 N LOGAN
Mailing Address - Street 2:SUITE 3
Mailing Address - City:DANVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61832
Mailing Address - Country:US
Mailing Address - Phone:217-442-3268
Mailing Address - Fax:217-442-3268
Practice Address - Street 1:733 N LOGAN
Practice Address - Street 2:SUITE 3
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832
Practice Address - Country:US
Practice Address - Phone:217-442-3268
Practice Address - Fax:217-442-3268
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL9200165OtherBLBS
IL117269OtherTRUST MARK HEALTH LINK
C51980Medicare UPIN
IL225490Medicare ID - Type Unspecified
IN143440Medicare ID - Type Unspecified