Basic Information
| Provider Information | |||||||||
| NPI: | 1144222324 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOGINENI | ||||||||
| FirstName: | RAVINDRA | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1021 QUARRIER ST | ||||||||
| Address2: | STE 301 | ||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253012313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043434625 | ||||||||
| FaxNumber: | 3043434626 | ||||||||
| Practice Location | |||||||||
| Address1: | 1021 QUARRIER ST | ||||||||
| Address2: | STE 301 | ||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253012313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043434625 | ||||||||
| FaxNumber: | 3043434626 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2005 | ||||||||
| LastUpdateDate: | 09/07/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 12675 | WV | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 0123331000 | 05 | WV | MEDICAID | 001718792 | 01 | WV | BLUE CROSS | OTHER |