Healthcare Provider Details

I. General information

NPI: 1700303914
Provider Name (Legal Business Name): MOHAN SAI RAVI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2017
Last Update Date: 09/21/2026
Certification Date: 09/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 W HAY ST STE 213
DECATUR IL
62526-4169
US

IV. Provider business mailing address

304 W HAY ST STE 213
DECATUR IL
62526-4169
US

V. Phone/Fax

Practice location:
  • Phone: 217-876-6640
  • Fax: 217-876-6645
Mailing address:
  • Phone: 217-876-6640
  • Fax: 217-876-6645

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number1022385
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberA179763
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number036179467
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: