Basic Information
| Provider Information | |||||||||
| NPI: | 1164729083 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RAVICH | ||||||||
| FirstName: | MARINA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1370 JOHNSON AVE | ||||||||
| Address2: | STE 102 | ||||||||
| City: | BRIDGEPORT | ||||||||
| State: | WV | ||||||||
| PostalCode: | 263301492 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6813423463 | ||||||||
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| Practice Location | |||||||||
| Address1: | 115 CASS AVE | ||||||||
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| City: | WOONSOCKET | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028954705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5127303060 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2011 | ||||||||
| LastUpdateDate: | 09/30/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD15211 | RI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 25617 | WV | Y | Allopathic & Osteopathic Physicians | Hospitalist |
No ID Information.