Basic Information
| Provider Information | |||||||||
| NPI: | 1447297635 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RAVENEL | ||||||||
| FirstName: | SAMUEL | ||||||||
| MiddleName: | DUBOSE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1701 WESTCHESTER DRIVE | ||||||||
| Address2: | SUITE 850 | ||||||||
| City: | HIGH POINT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272627254 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3368022400 | ||||||||
| FaxNumber: | 3368022534 | ||||||||
| Practice Location | |||||||||
| Address1: | 1814 WESTCHESTER DRIVE | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | HIGH POINT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272623832 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3368022100 | ||||||||
| FaxNumber: | 3368022101 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2006 | ||||||||
| LastUpdateDate: | 03/22/2010 | ||||||||
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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 | 208000000X | 14283 | NC | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 8970539 | 05 | NC | MEDICAID |