Healthcare Provider Details

I. General information

NPI: 1043379803
Provider Name (Legal Business Name): SUBHASCHANDRA REDDY RAVI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 W MAIN ST
HARTFORD MI
49057-1005
US

IV. Provider business mailing address

30 W MAIN ST
HARTFORD MI
49057-1005
US

V. Phone/Fax

Practice location:
  • Phone: 269-621-2166
  • Fax: 269-621-2566
Mailing address:
  • Phone: 269-621-2166
  • Fax: 269-621-2566

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number4301037460
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: