=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497195390
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RAVISH ASHOKKUMAR KOTHARI MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/25/2013
-----------------------------------------------------
Last Update Date | 03/10/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8 MED PARK STE 420 NEUROLOGY
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29203
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-545-6072
-----------------------------------------------------
Fax | 803-545-6051
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 300 E MCBEE AVE FL 4
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29601-2842
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-434-6412
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084V0102X
-----------------------------------------------------
Taxonomy Name | Vascular Neurology Physician
-----------------------------------------------------
License Number | 35909
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------