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General NPI Number Information
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NPI Number | 1427982818
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Entity Type | Organization
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Legal Business Name | SOUTH ALABAMA DERMATOLOGY AND SURGERY CENTER LLC
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Dates
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Enumeration Date | 06/10/2026
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Last Update Date | 06/10/2026
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Provider Practice Location Address
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Address Line | 10747 REDFERN RD
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City | DAPHNE
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State | AL
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Zip | 36526-6524
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Country | US
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Telephone | 917-836-5771
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 214
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City | LOXLEY
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State | AL
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Zip | 36551-0214
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | LARISA RAVITSKIY
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Credential | MD
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Telephone | 917-693-9625
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207ND0101X
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Taxonomy Name | MOHS-Micrographic Surgery Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number |
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License Number State |
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