Active NPI
PG Ravindranathan, MD
- Family Medicine Physician
- Mount Vernon, IL
National Provider Identifier
1477707149
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Family Medicine Physician
- License
- 036046577
- Practice address
- 2409 Broadway St
Mount Vernon, IL 62864-2917 - Phone
- (618) 696-2311
- NPI assigned
- Nov 7, 2008
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician | 207Q00000X | 036046577 | IL | Primary |
Addresses
Primary practice location
2409 Broadway St
Mount Vernon, IL 62864-2917
Mailing address
2409 Broadway St
Mount Vernon, IL 62864-2917
Phone (618) 696-2311
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 036046577 | IL | MD | Family Medicine Physician |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1226016000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1226016000000",
"number": "1477707149",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "2409 BROADWAY ST",
"city": "MOUNT VERNON",
"state": "IL",
"postal_code": "628642917",
"telephone_number": "618-696-2311"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "2409 BROADWAY ST",
"city": "MOUNT VERNON",
"state": "IL",
"postal_code": "628642917",
"telephone_number": "618-696-2311"
}
],
"practiceLocations": [],
"basic": {
"last_name": "RAVINDRANATHAN",
"first_name": "PG",
"credential": "MD",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2008-11-07",
"last_updated": "2008-11-07",
"status": "A"
},
"taxonomies": [
{
"code": "207Q00000X",
"taxonomy_group": "",
"desc": "Family Medicine",
"state": "IL",
"license": "036046577",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Mount Vernon, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 7, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.