Healthcare Provider Details

I. General information

NPI: 1477768141
Provider Name (Legal Business Name): MADAIAH REVANA MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 08/11/2022
Certification Date: 08/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18955 N MEMORIAL DR STE 400
HUMBLE TX
77338-4264
US

IV. Provider business mailing address

18955 N MEMORIAL DR STE 400
HUMBLE TX
77338-4264
US

V. Phone/Fax

Practice location:
  • Phone: 281-446-4638
  • Fax: 281-973-9454
Mailing address:
  • Phone: 281-446-4638
  • Fax: 281-973-9454

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207UN0902X
TaxonomyNuclear Imaging & Therapy Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number State

VIII. Authorized Official

Name: MADAIAH REVANA
Title or Position: OWNER
Credential: MD
Phone: 281-446-4638