Basic Information
| Provider Information | |||||||||
| NPI: | 1629048962 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RAGHAVENDRA | ||||||||
| FirstName: | MEDA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2160 S FIRST AVE | ||||||||
| Address2: | (15750 MARIAN DR., HOMER GLEN, IL. 60526) | ||||||||
| City: | MAYWOOD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7082166462 | ||||||||
| FaxNumber: | 7082161249 | ||||||||
| Practice Location | |||||||||
| Address1: | 2160 S FIRST AVE | ||||||||
| Address2: | (15750 MARIAN DR., HOMER GLEN, IL. 60526) | ||||||||
| City: | MAYWOOD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7082166462 | ||||||||
| FaxNumber: | 7082161249 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2006 | ||||||||
| LastUpdateDate: | 03/04/2010 | ||||||||
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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 | 208VP0014X | 36092881 | IL | Y | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
No ID Information.