Basic Information
| Provider Information | |||||||||
| NPI: | 1821020330 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RAVINDRAN | ||||||||
| FirstName: | WIJEYADEVENDRAM | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 155 | ||||||||
| Address2: | |||||||||
| City: | CHESWICK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 150240155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4128261065 | ||||||||
| FaxNumber: | 4128261491 | ||||||||
| Practice Location | |||||||||
| Address1: | 99 ROUTE 37 W | ||||||||
| Address2: | |||||||||
| City: | TOMS RIVER | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 087556423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7325578000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 01/17/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 25MA04096700 | NJ | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 930029622 | 01 | RAILROAD MEDICARE | OTHER | 3946002 | 05 | NJ | MEDICAID |