Healthcare Provider Details

I. General information

NPI: 1548963135
Provider Name (Legal Business Name): SAI SUSMITHA RAVI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2023
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5841 S MARYLAND AVE
CHICAGO IL
60637-1443
US

IV. Provider business mailing address

180 HARVESTER DR STE 110
BURR RIDGE IL
60527-4503
US

V. Phone/Fax

Practice location:
  • Phone: 757-446-6177
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number036180604
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: