Provider Demographics
NPI:1588730063
Name:AMEERUDDIN, REVATHY (MD)
Entity type:Individual
Prefix:
First Name:REVATHY
Middle Name:
Last Name:AMEERUDDIN
Suffix:
Gender:F
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:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:24 JOLIET ST STE 101
Practice Address - Street 2:
Practice Address - City:DYER
Practice Address - State:IN
Practice Address - Zip Code:46311-1705
Practice Address - Country:US
Practice Address - Phone:219-864-2059
Practice Address - Fax:219-864-2644
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN010-81500A208100000X
CAA84433208100000X
IN01061500A208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A844330Medicaid
IN200943400Medicaid
CA00A844330Medicaid
00A844330Medicare ID - Type Unspecified
IN209943400Medicaid