MEDICARE: RAVILLAMED PLLC

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	207P00000X	Emergency Medicine Physician
2	208D00000X	General Practice Physician

General Provider Information

NPI Number	:	1922838473
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RAVILLAMED PLLC

Provider Business Mailing Address
First Line	:	58 JUNIPER TER
Second Line	:
City	:	TUXEDO PARK
State	:	NY
Zip	:	10987-4769
Country	:	US
Telephone Number	:	973-400-9564
Fax Number	:

Provider Business Practice Location Address
First Line	:	2119 E NORRIS ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19125-1924
Country	:	US
Telephone Number	:	973-400-9564
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. AVINASH RAVILLA
Credential	:	DO
Telephone Number	:	973-400-9564

Provider Enumeration Date	:	08/07/2024
Last Update Date	:	02/03/2026

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Directions to “RAVILLAMED PLLC ” Practice Location

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