Provider Demographics
NPI:1164460465
Name:RAVIN, ADAM (MD)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:
Last Name:RAVIN
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 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 MEDICAL PARK DR
Practice Address - Street 2:STE 520
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2982
Practice Address - Country:US
Practice Address - Phone:704-403-2760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200301042208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC232009OtherMEDICARE GROUP PTAN - NORTHEAST PLASTIC & RECONSTRUCTIVE SURGERY
NC143AROtherBSNC
NC5911606Medicaid
NCDO2646OtherRAILROAD MEDICARE
NC2053619BOtherMEDICARE PTAN (LINKED TO NE PLASTIC & RECONSTRUCTIVE SURGERY)
NCP00667059OtherRAILROAD MEDICARE
NCP00667059OtherRAILROAD MEDICARE