Provider Demographics
NPI:1376524520
Name:RAVETZ, PAMELA (MD)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:RAVETZ
Suffix:
Gender:F
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 13579
Mailing Address - Street 2:
Mailing Address - City:READING
Mailing Address - State:PA
Mailing Address - Zip Code:19612-3579
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1350 BROADCASTING RD
Practice Address - Street 2:SUITE 201
Practice Address - City:WYOMISSING
Practice Address - State:PA
Practice Address - Zip Code:19610-3229
Practice Address - Country:US
Practice Address - Phone:611-685-9600
Practice Address - Fax:610-685-6700
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD069650L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001801614Medicaid
PA038252Medicare PIN