Basic Information
| Provider Information | |||||||||
| NPI: | 1376505081 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RAVALESE | ||||||||
| FirstName: | JOSEPH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1020A E BOAL AVE | ||||||||
| Address2: | |||||||||
| City: | BOALSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 168271509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8142378627 | ||||||||
| FaxNumber: | 8142380083 | ||||||||
| Practice Location | |||||||||
| Address1: | 25 NEWELL RD | ||||||||
| Address2: | SUITE C11 | ||||||||
| City: | BRISTOL | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060105100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8605829800 | ||||||||
| FaxNumber: | 8605850059 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2006 | ||||||||
| LastUpdateDate: | 12/11/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | 039160 | CT | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 010039160CT01 | 01 | CT | ANTHEM BCBS | OTHER | OV7350 | 01 | CT | PHS/HEALTHNET | OTHER | 001391606 | 05 | CT | MEDICAID | 039160 | 01 | CT | CONNECTICARE | OTHER | P2354315 | 01 | CT | OXFORD | OTHER |