Provider Demographics
NPI:1447297635
Name:RAVENEL, SAMUEL DUBOSE (MD)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:DUBOSE
Last Name:RAVENEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 WESTCHESTER DRIVE
Mailing Address - Street 2:SUITE 850
Mailing Address - City:HIGH POINT
Mailing Address - State:NC
Mailing Address - Zip Code:27262-7254
Mailing Address - Country:US
Mailing Address - Phone:336-802-2400
Mailing Address - Fax:336-802-2534
Practice Address - Street 1:1814 WESTCHESTER DRIVE
Practice Address - Street 2:SUITE 203
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27262-3832
Practice Address - Country:US
Practice Address - Phone:336-802-2100
Practice Address - Fax:336-802-2101
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2010-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC14283208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8970539Medicaid
F39674Medicare UPIN