MEDICARE: MADAIAH REVANA MD PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RI0011X	Interventional Cardiology Physician	E7719	TX
2	207UN0902X	Nuclear Imaging & Therapy Physician	E7719	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	390396	OTHER	TX	WELLCARE
2	742018542	OTHER		TAX ID
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	82G136	OTHER		BCBS
5	10016000	OTHER	TX	AMERIGROUP

General Provider Information

NPI Number	:	1013997360
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MADAIAH REVANA MD PA

Provider Business Mailing Address
First Line	:	18955 N MEMORIAL DR STE 400
Second Line	:
City	:	HUMBLE
State	:	TX
Zip	:	77338-4264
Country	:	US
Telephone Number	:	281-446-4638
Fax Number	:	281-446-5386

Provider Business Practice Location Address
First Line	:	9816 MEMORIAL BLVD STE 107
Second Line	:
City	:	HUMBLE
State	:	TX
Zip	:	77338-4205
Country	:	US
Telephone Number	:	281-446-4638
Fax Number	:	281-973-9454

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/20/2006
Last Update Date	:	01/15/2026

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Directions to “ MADAIAH REVANA MD PA” Practice Location

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