Provider Demographics
NPI:1366862906
Name:REAVEN, ANDREW
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:REAVEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 WEST MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055-1822
Mailing Address - Country:US
Mailing Address - Phone:220-564-4218
Mailing Address - Fax:220-564-4217
Practice Address - Street 1:1320 WEST MAIN STREET
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-1822
Practice Address - Country:US
Practice Address - Phone:220-564-4218
Practice Address - Fax:220-564-4217
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-22
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.129596207L00000X
NC2018-00740207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty