Healthcare Provider Details

I. General information

NPI: 1861447906
Provider Name (Legal Business Name): THULASIRAMAN P RAVICHANDRAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 03/11/2020
Certification Date: 03/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2025 W OKLAHOMA AVE SUITE 120
MILWAUKEE WI
53215-4455
US

IV. Provider business mailing address

2025 W OKLAHOMA AVE SUITE 120
MILWAUKEE WI
53215-4455
US

V. Phone/Fax

Practice location:
  • Phone: 414-382-8960
  • Fax: 414-382-8975
Mailing address:
  • Phone: 414-382-8960
  • Fax: 414-382-8975

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number38984-020
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code2084D0003X
TaxonomyDiagnostic Neuroimaging (Psychiatry & Neurology) Physician
License Number38984-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: