MEDICARE: DR. KONDARAMVALAPPIL K RAVINDRAN MD

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	4301037197	MI
2	207UN0901X	Nuclear Cardiology Physician	4301037197	MI
3	207RC0000X	Cardiovascular Disease Physician	43010037197	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	KR037197	OTHER	MI	LICENSE #

General Provider Information

NPI Number	:	1790771319
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KONDARAMVALAPPIL K RAVINDRAN MD

Provider Business Mailing Address
First Line	:	900 COOPER AVE
Second Line	:	SUITE 4100
City	:	SAGINAW
State	:	MI
Zip	:	48602-5182
Country	:	US
Telephone Number	:	989-497-9395
Fax Number	:	989-497-9599

Provider Business Practice Location Address
First Line	:	900 COOPER AVE
Second Line	:	SUITE 4100
City	:	SAGINAW
State	:	MI
Zip	:	48602-5182
Country	:	US
Telephone Number	:	989-497-9395
Fax Number	:	989-497-9599

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

Provider Enumeration Date	:	09/20/2005
Last Update Date	:	10/19/2012

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