Provider Demographics
NPI:1750377636
Name:SUPPIAH, RAVICHANDRAN (MD)
Entity type:Individual
Prefix:MR
First Name:RAVICHANDRAN
Middle Name:
Last Name:SUPPIAH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:11781 LEE JACKSON MEMORIAL HWY
Mailing Address - Street 2:SUITE 550
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-3309
Mailing Address - Country:US
Mailing Address - Phone:571-777-5102
Mailing Address - Fax:703-563-6256
Practice Address - Street 1:325 S BELMONT ST
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17403-2608
Practice Address - Country:US
Practice Address - Phone:800-463-4326
Practice Address - Fax:717-263-1566
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2015-09-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD426377207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02933397Medicaid
PA1014407760001Medicaid
NY51961X1091Medicare PIN
PAI48652Medicare UPIN
NY02933397Medicaid