Provider Demographics
NPI:1801801717
Name:RAVI, LATHA (MD)
Entity type:Individual
Prefix:MRS
First Name:LATHA
Middle Name:
Last Name:RAVI
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 1:180 SOUTH THIRD STREET
Mailing Address - Street 2:SUITE 102
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62220
Mailing Address - Country:US
Mailing Address - Phone:618-235-2511
Mailing Address - Fax:618-235-2548
Practice Address - Street 1:180 SOUTH THIRD STREET
Practice Address - Street 2:SUITE 102
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62220
Practice Address - Country:US
Practice Address - Phone:618-235-2511
Practice Address - Fax:618-235-2548
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-29
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-072768208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0008200539OtherBCBS OF IL
IL250002252OtherRAILROAD MEDICARE PIN
33725OtherGROUP HEALTH PLAN
IL0008200539OtherBCBS OF IL
D16212Medicare UPIN
IL758520Medicare PIN