MEDICARE: RANJINI B GANDHAVADI M.D.

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	2085R0001X	Radiation Oncology Physician	22791-020	WI
2	2085R0203X	Therapeutic Radiology Physician	22791-020	WI

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	920005883	OTHER	WI	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1518958057
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RANJINI B GANDHAVADI M.D.

Provider Business Mailing Address
First Line	:	4425 N PORT WASHINGTON RD
Second Line	:	ATTN: CSMCP CLINIC CREDENTIALING
City	:	GLENDALE
State	:	WI
Zip	:	53212-1082
Country	:	US
Telephone Number	:	414-291-1556
Fax Number	:	414-291-1557

Provider Business Practice Location Address
First Line	:	2350 N LAKE DR
Second Line	:	SUITE G01
City	:	MILWAUKEE
State	:	WI
Zip	:	53211-4528
Country	:	US
Telephone Number	:	414-291-1556
Fax Number	:	414-291-1557

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/03/2005
Last Update Date	:	06/11/2012

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Directions to “ RANJINI B GANDHAVADI M.D.” Practice Location

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