MEDICARE: RAVI PACHIGOLLA MD PSC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Y00000X	Otolaryngology Physician	K4763	TX

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	00Z738	OTHER	TX	MEDICARE GROUP PIN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	1295932549	OTHER		GROUP NPI #
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	38283	OTHER	KY	LICENSE NUMBER
6	K4763	OTHER	TX	TEXAS LICENSE
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1295932549
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RAVI PACHIGOLLA MD PSC

Provider Business Mailing Address
First Line	:	2016 FORT WORTH HWY
Second Line	:
City	:	WEATHERFORD
State	:	TX
Zip	:	76086-4706
Country	:	US
Telephone Number	:	817-596-8637
Fax Number	:	817-599-3614

Provider Business Practice Location Address
First Line	:	2016 FORT WORTH HWY
Second Line	:
City	:	WEATHERFORD
State	:	TX
Zip	:	76086-4706
Country	:	US
Telephone Number	:	817-596-8637
Fax Number	:	817-599-3614

Authorized Official
Title or Position	:	PHYSICIAN
Name	:	DR. RAVI V PACHIGOLLA
Credential	:	M.D.
Telephone Number	:	817-596-8637

Provider Enumeration Date	:	06/29/2007
Last Update Date	:	04/28/2022

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