MEDICARE: RAVEN LIONEL DELOATCH 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	207R00000X	Internal Medicine Physician	31478	NC

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	110147756	OTHER	NC	RAILROAD MEDICARE #

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	28324	OTHER	NC	BLUE CROSS BLUE SHIELD #
3	0454365	OTHER	NC	UNITED HEALTH CARE #
4	D2792	OTHER	NC	MEDCOST LLC PROVIDER #
5	31478	OTHER	NC	NC MEDICAL LICENSE #
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
7	112536	OTHER	NC	ANTHEM SERVICES PROVIDER#
8	289354	OTHER	NC	MAMSI PROVIDER #

General Provider Information

NPI Number	:	1740268598
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RAVEN LIONEL DELOATCH MD

Provider Business Mailing Address
First Line	:	PO BOX 640
Second Line	:
City	:	ROANOKE RAPIDS
State	:	NC
Zip	:	27870-0640
Country	:	US
Telephone Number	:	252-536-5791
Fax Number	:	252-536-5444

Provider Business Practice Location Address
First Line	:	9425 NC HIGHWAY 305
Second Line	:
City	:	JACKSON
State	:	NC
Zip	:	27845-9679
Country	:	US
Telephone Number	:	252-534-1661
Fax Number	:	252-534-2841

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

Provider Enumeration Date	:	01/03/2006
Last Update Date	:	03/07/2023

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Directions to “ RAVEN LIONEL DELOATCH MD” Practice Location

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