Basic Information
Provider Information
NPI: 1184679375
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: RAVENEL
FirstName: SAMUEL
MiddleName: FITZSIMONS
NamePrefix:  
NameSuffix: II
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 2315 W JACKSON ST
Address2:  
City: PENSACOLA
State: FL
PostalCode: 325057552
CountryCode: US
TelephoneNumber: 8504364630
FaxNumber: 8504362095
Practice Location
Address1: 470 S HIGHWAY 29 STE 2
Address2:  
City: CANTONMENT
State: FL
PostalCode: 325336314
CountryCode: US
TelephoneNumber: 8507800111
FaxNumber: 8507800642
Other Information
ProviderEnumerationDate: 05/24/2006
LastUpdateDate: 09/24/2019
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
208000000XME128058FLY Allopathic & Osteopathic PhysiciansPediatrics 

ID Information
IDTypeStateIssuerDescription
01791960005FL MEDICAID
M8P0401FLBCBS FLOTHER
KD91501FLMCR FLOTHER


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