Provider Demographics
NPI:1386185346
Name:RAVEGUM, MICHAEL (CP, BOCPO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:RAVEGUM
Suffix:
Gender:M
Credentials:CP, BOCPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2708 EASTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17402-3910
Mailing Address - Country:US
Mailing Address - Phone:717-515-6000
Mailing Address - Fax:
Practice Address - Street 1:32 WEST RD
Practice Address - Street 2:SUITE 120
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-2302
Practice Address - Country:US
Practice Address - Phone:717-515-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-10
Last Update Date:2017-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPO000181174400000X
PAOH000262174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist