MEDICARE: ANTONIO SERRA RAVIDA M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208100000X	Physical Medicine & Rehabilitation Physician	DO028572	MD

General Provider Information

NPI Number	:	1366772220
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANTONIO SERRA RAVIDA M.D.

Provider Business Mailing Address
First Line	:	1120 SAINT PAUL ST
Second Line	:	GROUND LEVEL
City	:	BALTIMORE
State	:	MD
Zip	:	21202-2618
Country	:	US
Telephone Number	:	410-685-7790
Fax Number	:	410-685-5360

Provider Business Practice Location Address
First Line	:	1120 SAINT PAUL ST
Second Line	:	GROUND LEVEL
City	:	BALTIMORE
State	:	MD
Zip	:	21202-2618
Country	:	US
Telephone Number	:	410-685-7790
Fax Number	:	410-685-5360

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/28/2009
Last Update Date	:	12/28/2009

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