Healthcare Provider Details

I. General information

NPI: 1003035460
Provider Name (Legal Business Name): SUE VAUTHIER RAVER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12501 WILLOWBROOK RD ALLEGANY COUNTY HEALTH DEPARTMENT
CUMBERLAND MD
21501-1745
US

IV. Provider business mailing address

12501 WILLOWBROOK RD ALLEGANY COUNTY HEALTH DEPARTMENT
CUMBERLAND MD
21501-1745
US

V. Phone/Fax

Practice location:
  • Phone: 301-759-5001
  • Fax: 301-777-5674
Mailing address:
  • Phone: 301-759-5001
  • Fax: 301-777-5674

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD0020805
License Number StateMD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: