Provider Demographics
NPI:1720057862
Name:SRINIVASAN, RAGHURAMAN (MD)
Entity Type:Individual
Prefix:
First Name:RAGHURAMAN
Middle Name:
Last Name:SRINIVASAN
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 1:450A TUCKER DR
Mailing Address - Street 2:
Mailing Address - City:MAYSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41056-9110
Mailing Address - Country:US
Mailing Address - Phone:606-759-0339
Mailing Address - Fax:606-759-0139
Practice Address - Street 1:450A TUCKER DR
Practice Address - Street 2:
Practice Address - City:MAYSVILLE
Practice Address - State:KY
Practice Address - Zip Code:41056-9110
Practice Address - Country:US
Practice Address - Phone:606-759-0339
Practice Address - Fax:606-759-0139
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2013-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY28708207RC0000X, 207RI0011X, 207UN0901X
OH35077864S207RC0000X, 207RI0011X, 207UN0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810020951Medicaid
KY64287089Medicaid
OH9321441OtherOH MEDICARE GRP #
KY6293OtherKY MEDICARE GRP #
OH2144594Medicaid
OH2144594Medicaid
KY64287089Medicaid
KYK013940Medicare PIN
KY0629301Medicare PIN