Basic Information
| Provider Information | |||||||||
| NPI: | 1508915307 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REVANKAR | ||||||||
| FirstName: | RAJAN | ||||||||
| MiddleName: | RAMESH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M. D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1701 WESTCHESTER DR | ||||||||
| Address2: | STE 850 | ||||||||
| City: | HIGH POINT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272627254 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3368022400 | ||||||||
| FaxNumber: | 3368022001 | ||||||||
| Practice Location | |||||||||
| Address1: | 2630 WILLARD DAIRY RD STE 301 | ||||||||
| Address2: | |||||||||
| City: | HIGH POINT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272658354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3368843720 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2007 | ||||||||
| LastUpdateDate: | 08/25/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 9900659 | NC | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | P00655198 | 01 | NC | RR MEDICARE | OTHER | 8912054 | 05 | NC | MEDICAID |