Provider Demographics
NPI:1316957871
Name:RAVITZ, BERNARD HOWARD (MD)
Entity type:Individual
Prefix:DR
First Name:BERNARD
Middle Name:HOWARD
Last Name:RAVITZ
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:PO BOX 180
Mailing Address - Street 2:
Mailing Address - City:MARYLAND LINE
Mailing Address - State:MD
Mailing Address - Zip Code:21105-0180
Mailing Address - Country:US
Mailing Address - Phone:443-829-3319
Mailing Address - Fax:443-444-4897
Practice Address - Street 1:5601 LOCH RAVEN BLVD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21239-2945
Practice Address - Country:US
Practice Address - Phone:443-444-3926
Practice Address - Fax:443-444-4897
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2016-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0036846207P00000X, 207R00000X, 207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD067341200Medicaid
MD8666BHOtherBLUE CROSS BLUE SHIELD
MDE42983Medicare UPIN
MDE42983Medicare UPIN
MD421MMedicare ID - Type UnspecifiedOLD GROUP NUMBER