Healthcare Provider Details

I. General information

NPI: 1265418420
Provider Name (Legal Business Name): GANESHAN RAVEENDRAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 FULTON ST SE
MINNEAPOLIS MN
55455-4800
US

IV. Provider business mailing address

420 DELAWARE ST SE MMC- 508
MINNEAPOLIS MN
55455-0341
US

V. Phone/Fax

Practice location:
  • Phone: 612-672-7422
  • Fax:
Mailing address:
  • Phone: 612-626-4238
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number42353
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: