1194882571 NPI number — VIDYASHANKAR B REVAN M.D

Table of content: VIDYASHANKAR B REVAN M.D (NPI 1194882571)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194882571 NPI number — VIDYASHANKAR B REVAN M.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
REVAN
Provider First Name:
VIDYASHANKAR
Provider Middle Name:
B
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
REVANNASIDDAPPA
Provider Other First Name:
VIDYASHANKAR
Provider Other Middle Name:
B
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1194882571
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/26/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9800 SHELBYVILLE RD STE 220
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40223-2992
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-429-8585
Provider Business Mailing Address Fax Number:
502-753-0889

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
110 FAIRWAY DR
Provider Second Line Business Practice Location Address:
SUITE # 2
Provider Business Practice Location Address City Name:
WILMINGTON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45177-8756
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-655-9179
Provider Business Practice Location Address Fax Number:
937-655-9139
Provider Enumeration Date:
01/03/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207K00000X , with the licence number:  35080833 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2321660 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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