Healthcare Provider Details

I. General information

NPI: 1316296411
Provider Name (Legal Business Name): KATHLEEN M. RAVIELE, MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2012
Last Update Date: 07/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2799 LAWRENCEVILLE HWY SUITE 110
DECATUR GA
30033-2517
US

IV. Provider business mailing address

2799 LAWRENCEVILLE HWY SUITE 110
DECATUR GA
30033-2517
US

V. Phone/Fax

Practice location:
  • Phone: 770-491-0255
  • Fax: 770-491-8157
Mailing address:
  • Phone: 770-491-0255
  • Fax: 770-491-8157

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number020801
License Number StateGA

VIII. Authorized Official

Name: CAROL H GARRISON
Title or Position: INSURANCE
Credential:
Phone: 770-491-0255