Provider Demographics
NPI:1316296411
Name:KATHLEEN M. RAVIELE, MD PC
Entity type:Organization
Organization Name:KATHLEEN M. RAVIELE, MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:H
Authorized Official - Last Name:GARRISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-491-0255
Mailing Address - Street 1:2799 LAWRENCEVILLE HWY
Mailing Address - Street 2:SUITE 110
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-2517
Mailing Address - Country:US
Mailing Address - Phone:770-491-0255
Mailing Address - Fax:770-491-8157
Practice Address - Street 1:2799 LAWRENCEVILLE HWY
Practice Address - Street 2:SUITE 110
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-2517
Practice Address - Country:US
Practice Address - Phone:770-491-0255
Practice Address - Fax:770-491-8157
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-05
Last Update Date:2015-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA020801207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000179935CMedicaid
GA16BDCCBOtherMEDICARE PTAN
GA16BDCCBOtherMEDICARE PTAN