1760402861 NPI number — TIMOTHY G RAVEILL MD

Table of content: TIMOTHY G RAVEILL MD (NPI 1760402861)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760402861 NPI number — TIMOTHY G RAVEILL MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RAVEILL
Provider First Name:
TIMOTHY
Provider Middle Name:
G
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1760402861
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/11/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9212 NIEMAN RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OVERLAND PARK
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66214-1868
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
913-599-6777
Provider Business Mailing Address Fax Number:
913-599-3955

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2525 GLENN HENDREN DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LIBERTY
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64068-9625
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
816-407-2038
Provider Business Practice Location Address Fax Number:
816-792-7135
Provider Enumeration Date:
07/20/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  2000165897 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 29296026 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".