Provider Demographics
NPI:1730156993
Name:BOLLA, RAVISANKAR R (MD)
Entity type:Individual
Prefix:
First Name:RAVISANKAR
Middle Name:R
Last Name:BOLLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6000 W CREEK RD STE 10
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:OH
Mailing Address - Zip Code:44131-2139
Mailing Address - Country:US
Mailing Address - Phone:800-223-2273
Mailing Address - Fax:
Practice Address - Street 1:20455 LORAIN RD
Practice Address - Street 2:SECOND FLOOR
Practice Address - City:FAIRVIEW PARK
Practice Address - State:OH
Practice Address - Zip Code:44126-3494
Practice Address - Country:US
Practice Address - Phone:440-333-8600
Practice Address - Fax:440-333-5015
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35059503B207RC0000X
OH35059503207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
10788832OtherCAQH
OH340714585OtherGROUP TIN NUMBER
F10567Medicare UPIN
34-1783789OtherGROUP TIN
F10567Medicare UPIN
0119204OtherGROUP MEDICAID
1780634279OtherGROUP NPI
F59503OtherSUMMACARE APEX
D368301OtherGROUP IND DIAGNOSTICS MED
341783789078OtherCARESOURCE
CA4511OtherRR MEDICARE GROUP
0644605OtherAETNA
10788832OtherCAQH
102944OtherKAISER
2501208OtherUNITED HEALTHCARE
3610861OtherGROUP ASC MEDICARE
OH0707714Medicare ID - Type Unspecified
OH0882095Medicaid
060028893OtherRR MEDICARE INDIVIDUAL