Provider Demographics
NPI:1003035460
Name:RAVER, SUE VAUTHIER (MD)
Entity Type:Individual
Prefix:DR
First Name:SUE
Middle Name:VAUTHIER
Last Name:RAVER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12501 WILLOWBROOK RD
Mailing Address - Street 2:ALLEGANY COUNTY HEALTH DEPARTMENT
Mailing Address - City:CUMBERLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21501-1745
Mailing Address - Country:US
Mailing Address - Phone:301-759-5001
Mailing Address - Fax:301-777-5674
Practice Address - Street 1:12501 WILLOWBROOK RD
Practice Address - Street 2:ALLEGANY COUNTY HEALTH DEPARTMENT
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21501-1745
Practice Address - Country:US
Practice Address - Phone:301-759-5001
Practice Address - Fax:301-777-5674
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0020805208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
D78148Medicare UPIN