Provider Demographics
NPI:1356397806
Name:RAVINIA MEDICAL LTD
Entity type:Organization
Organization Name:RAVINIA MEDICAL LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:RODOLFO
Authorized Official - Middle Name:J
Authorized Official - Last Name:MEJICANO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-403-0431
Mailing Address - Street 1:9641 W 153RD ST
Mailing Address - Street 2:SUITE 48
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-3775
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9641 W 153RD ST
Practice Address - Street 2:SUITE 48
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-3775
Practice Address - Country:US
Practice Address - Phone:708-403-0431
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2010-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0001628037OtherBCBS
IL210764Medicare PIN
ILDC3122Medicare PIN
IL0001628037OtherBCBS