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
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | ME128058 | FL | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 017919600 | 05 | FL |   | MEDICAID | M8P04 | 01 | FL | BCBS FL | OTHER | KD915 | 01 | FL | MCR FL | OTHER |