MEDICARE: SAMUEL DUBOSE RAVENEL MD

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	208000000X	Pediatrics Physician	14283	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1447297635
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMUEL DUBOSE RAVENEL MD

Provider Business Mailing Address
First Line	:	1701 WESTCHESTER DRIVE
Second Line	:	SUITE 850
City	:	HIGH POINT
State	:	NC
Zip	:	27262-7254
Country	:	US
Telephone Number	:	336-802-2400
Fax Number	:	336-802-2534

Provider Business Practice Location Address
First Line	:	1814 WESTCHESTER DRIVE
Second Line	:	SUITE 203
City	:	HIGH POINT
State	:	NC
Zip	:	27262-3832
Country	:	US
Telephone Number	:	336-802-2100
Fax Number	:	336-802-2101

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

Provider Enumeration Date	:	05/31/2006
Last Update Date	:	03/22/2010

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