Provider Demographics
NPI:1134183742
Name:KADAM, RAVINA V (MD)
Entity type:Individual
Prefix:
First Name:RAVINA
Middle Name:V
Last Name:KADAM
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 1:303 MEDICAL DRIVE
Mailing Address - Street 2:STE 406
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-4145
Mailing Address - Country:US
Mailing Address - Phone:706-880-7361
Mailing Address - Fax:706-812-2657
Practice Address - Street 1:300 MEDICAL DR STE 704
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-4130
Practice Address - Country:US
Practice Address - Phone:706-880-7361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL28388207R00000X
MO2005037959207R00000X
GA62902207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO202193OtherBLUE SHIELD/BLUE CHOICE
MO732685OtherHEALTHLINK
MOP00310560OtherRR MEDICARE
MO200455004Medicaid
AL510I110039Medicare PIN
MO202193OtherBLUE SHIELD/BLUE CHOICE
MO732685OtherHEALTHLINK
MO938181444Medicare PIN