Provider Demographics
NPI:1184679375
Name:RAVENEL, SAMUEL FITZSIMONS II (MD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:FITZSIMONS
Last Name:RAVENEL
Suffix:II
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 1:2315 W JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32505-7552
Mailing Address - Country:US
Mailing Address - Phone:850-436-4630
Mailing Address - Fax:850-436-2095
Practice Address - Street 1:470 S HIGHWAY 29 STE 2
Practice Address - Street 2:
Practice Address - City:CANTONMENT
Practice Address - State:FL
Practice Address - Zip Code:32533-6314
Practice Address - Country:US
Practice Address - Phone:850-780-0111
Practice Address - Fax:850-780-0642
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME128058208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL017919600Medicaid
FLM8P04OtherBCBS FL
FLKD915OtherMCR FL