1770689481 NPI number — RAVENSWOOD FAMILY MEDICINE CTR

Table of content: (NPI 1770689481)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770689481 NPI number — RAVENSWOOD FAMILY MEDICINE CTR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RAVENSWOOD FAMILY MEDICINE CTR
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1770689481
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/22/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 325
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RAVENSWOOD
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
26164-0325
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-273-4479
Provider Business Mailing Address Fax Number:
304-273-2599

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
316 WASHINGTON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RAVENSWOOD
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26164-1704
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-273-2647
Provider Business Practice Location Address Fax Number:
304-273-2636
Provider Enumeration Date:
09/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MALIK
Authorized Official First Name:
ARIF
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
304-903-4579

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  19979 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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