Healthcare Provider Details

I. General information

NPI: 1639492473
Provider Name (Legal Business Name): RAHN ANTONIO RAVENELL DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2010
Last Update Date: 10/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

171 ASHLEY AVE
CHARLESTON SC
29425-1810
US

IV. Provider business mailing address

PO BOX 751461
CHARLOTTE NC
28275-1461
US

V. Phone/Fax

Practice location:
  • Phone: 843-792-1414
  • Fax:
Mailing address:
  • Phone: 843-792-6200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPOD001109
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number603
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: