1013997360 NPI number — MADAIAH REVANA MD PA

Table of content: MADAIAH REVANA MD PA (NPI 1013997360)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013997360 NPI number — MADAIAH REVANA MD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
REVANA
Provider First Name:
MADAIAH
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD PA
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:
1013997360
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/03/2026
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9816 MEMORIAL BLVD
Provider Second Line Business Mailing Address:
STE 107, STE 120 (TESTING)
Provider Business Mailing Address City Name:
HUMBLE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77338-4264
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
281-446-4638
Provider Business Mailing Address Fax Number:
281-446-5386

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9816 MEMORIAL BLVD STE 107
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HUMBLE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77338-4205
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-446-4638
Provider Business Practice Location Address Fax Number:
281-973-9454
Provider Enumeration Date:
01/20/2006

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: 207RI0011X , with the licence number:  E7719 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207UN0902X , with the licence number: E7719 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 390396 . This is a "WELLCARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 742018542 . This is a "TAX ID" identifier . This identifiers is of the category "OTHER".
  • Identifier: 137528912 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 82G136 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 10016000 . This is a "AMERIGROUP" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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