Provider Demographics
NPI:1124381769
Name:RAVENNA, PAUL ANTHONY (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:ANTHONY
Last Name:RAVENNA
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 1:680 N LAKE SHORE DR
Mailing Address - Street 2:SUITE 1000
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-4546
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1333 W BELMONT AVE
Practice Address - Street 2:NORTHWESTERN MEDICINE
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-5785
Practice Address - Country:US
Practice Address - Phone:312-972-5115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-19
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036136981207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine