Basic Information
| Provider Information | |||||||||
| NPI: | 1700298254 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | VASSA | ||||||||
| FirstName: | RAVI | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 E 15TH ST | ||||||||
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| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787011930 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 680 N LAKE SHORE DR | ||||||||
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| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606114546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3126956868 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2014 | ||||||||
| LastUpdateDate: | 04/18/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | BP10050058 | TX | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 036145035 | IL | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.