Healthcare Provider Details

I. General information

NPI: 1205196599
Provider Name (Legal Business Name): RAVY K. VAJRAVELU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2012
Last Update Date: 09/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 CIVIC CENTER BLVD FL 4
PHILADELPHIA PA
19104-5127
US

IV. Provider business mailing address

3400 CIVIC CENTER BLVD FL 4
PHILADELPHIA PA
19104-5127
US

V. Phone/Fax

Practice location:
  • Phone: 215-349-8222
  • Fax: 215-662-6530
Mailing address:
  • Phone: 215-349-8222
  • Fax: 215-662-6530

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberMD457602
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD457602
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: