1356677835 NPI number — MR. RAVIKUMAR K SHUKLA RPT

Table of content: MR. RAVIKUMAR K SHUKLA RPT (NPI 1356677835)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356677835 NPI number — MR. RAVIKUMAR K SHUKLA RPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHUKLA
Provider First Name:
RAVIKUMAR
Provider Middle Name:
K
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
RPT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1356677835
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/10/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5511 W US HIGHWAY 10
Provider Second Line Business Mailing Address:
SUITE # B
Provider Business Mailing Address City Name:
LUDINGTON
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49431-2455
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
231-845-0900
Provider Business Mailing Address Fax Number:
231-845-0909

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
751 KENMOOR AVE SE
Provider Second Line Business Practice Location Address:
SUITE # E
Provider Business Practice Location Address City Name:
GRAND RAPIDS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49546-2388
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-954-7013
Provider Business Practice Location Address Fax Number:
616-954-7014
Provider Enumeration Date:
10/19/2009

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: 225100000X , with the licence number:  5501013597 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 5501013597 . This is a "STATE OF MICHIGAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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