Provider Demographics
NPI:1093973778
Name:MARJORIE C. RAVITZ DPM PC
Entity Type:Organization
Organization Name:MARJORIE C. RAVITZ DPM PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARJORIE
Authorized Official - Middle Name:C
Authorized Official - Last Name:RAVITZ
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:631-724-1166
Mailing Address - Street 1:260 MIDDLE COUNTRY RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-2982
Mailing Address - Country:US
Mailing Address - Phone:631-724-1166
Mailing Address - Fax:631-724-4130
Practice Address - Street 1:260 MIDDLE COUNTRY RD
Practice Address - Street 2:SUITE 104
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-2982
Practice Address - Country:US
Practice Address - Phone:631-724-1166
Practice Address - Fax:631-724-4130
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-29
Last Update Date:2009-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN4126213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY6202090001Medicare NSC
NYA100000153Medicare PIN