Provider Demographics
NPI:1376505081
Name:RAVALESE, JOSEPH (MD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:
Last Name:RAVALESE
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 1:1020A E BOAL AVE
Mailing Address - Street 2:
Mailing Address - City:BOALSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:16827-1509
Mailing Address - Country:US
Mailing Address - Phone:814-237-8627
Mailing Address - Fax:814-238-0083
Practice Address - Street 1:25 NEWELL RD
Practice Address - Street 2:SUITE C11
Practice Address - City:BRISTOL
Practice Address - State:CT
Practice Address - Zip Code:06010-5100
Practice Address - Country:US
Practice Address - Phone:860-582-9800
Practice Address - Fax:860-585-0059
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0391602085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT010039160CT01OtherANTHEM BCBS
CTOV7350OtherPHS/HEALTHNET
CT001391606Medicaid
CT039160OtherCONNECTICARE
CTP2354315OtherOXFORD
CTP2354315OtherOXFORD
CTG00108Medicare UPIN