Provider Demographics
NPI:1003854159
Name:SEVERT, RAYMOND (MD)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:
Last Name:SEVERT
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 1:1144 SONOMA AVE
Mailing Address - Street 2:SUITE 121
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-4812
Mailing Address - Country:US
Mailing Address - Phone:707-978-4322
Mailing Address - Fax:707-538-2519
Practice Address - Street 1:1144 SONOMA AVE
Practice Address - Street 2:SUITE 121
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-4812
Practice Address - Country:US
Practice Address - Phone:707-978-4322
Practice Address - Fax:707-538-2519
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-02
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG63482207X00000X, 207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G634820Medicaid
CA1003854159OtherMD CONDEREN MEDICAL BILLING
CA00G634820Medicaid
CA00G634820Medicare PIN
CAF28991Medicare UPIN
CA1003854159Medicare UPIN