Basic Information
| Provider Information | |||||||||
| NPI: | 1578632089 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POLAVARAPU | ||||||||
| FirstName: | RAVINDRA | ||||||||
| MiddleName: | NATH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 STEWART RD | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | MONROE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481625304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342401760 | ||||||||
| FaxNumber: | 7342401780 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 STEWART RD | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | MONROE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481625304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342401760 | ||||||||
| FaxNumber: | 7342401780 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 2084A0401X | 4301058454 | MI | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3476819 | 05 | MI | MEDICAID | 2605800952 | 01 | MI | BCBS | OTHER |