=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033151873
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RAVI GEORGE D.O.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/12/2006
-----------------------------------------------------
Last Update Date | 08/10/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 900 JORIE BLVD SUITE 186
-----------------------------------------------------
City | OAK BROOK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60523-2213
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-954-6700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 900 JORIE BLVD SUITE 186
-----------------------------------------------------
City | OAK BROOK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60523-2213
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-954-6700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RA0000X
-----------------------------------------------------
Taxonomy Name | Adolescent Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number | 036098555
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208M00000X
-----------------------------------------------------
Taxonomy Name | Hospitalist Physician
-----------------------------------------------------
License Number | 036098555
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------