Healthcare Provider Details

I. General information

NPI: 1447297635
Provider Name (Legal Business Name): SAMUEL DUBOSE RAVENEL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2006
Last Update Date: 03/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1814 WESTCHESTER DRIVE SUITE 203
HIGH POINT NC
27262-3832
US

IV. Provider business mailing address

1701 WESTCHESTER DRIVE SUITE 850
HIGH POINT NC
27262-7254
US

V. Phone/Fax

Practice location:
  • Phone: 336-802-2100
  • Fax: 336-802-2101
Mailing address:
  • Phone: 336-802-2400
  • Fax: 336-802-2534

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number14283
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: