Healthcare Provider Details

I. General information

NPI: 1427982818
Provider Name (Legal Business Name): SOUTH ALABAMA DERMATOLOGY AND SURGERY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2026
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10747 REDFERN RD
DAPHNE AL
36526-6524
US

IV. Provider business mailing address

PO BOX 214
LOXLEY AL
36551-0214
US

V. Phone/Fax

Practice location:
  • Phone: 917-836-5771
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: LARISA RAVITSKIY
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 917-693-9625