MEDICARE: MADAIAH REVANA MD PA

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	207UN0902X	Nuclear Imaging & Therapy Physician
2	207RI0011X	Interventional Cardiology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	10016000	OTHER	TX	AMERIGROUP
3	390396	OTHER	TX	WELLCARE
4	82G136	OTHER	TX	BCBS

General Provider Information

NPI Number	:	1477768141
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MADAIAH REVANA MD PA

Provider Business Mailing Address
First Line	:	9816 MEMORIAL BLVD STE 107
Second Line	:	SUITE 120 (TESTING)
City	:	HUMBLE
State	:	TX
Zip	:	77338-4205
Country	:	US
Telephone Number	:	281-446-4638
Fax Number	:	281-973-9454

Provider Business Practice Location Address
First Line	:	9816 MEMORIAL BLVD
Second Line	:	STE 107 STE 120 (TESTING)
City	:	HUMBLE
State	:	TX
Zip	:	77338-4205
Country	:	US
Telephone Number	:	281-446-4638
Fax Number	:	281-973-9454

Authorized Official
Title or Position	:	OWNER
Name	:	MADAIAH REVANA
Credential	:	MD
Telephone Number	:	281-446-4638

Provider Enumeration Date	:	05/14/2007
Last Update Date	:	02/03/2026

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