Provider Demographics
NPI:1568550499
Name:RAVIV, STACY M (MD)
Entity Type:Individual
Prefix:DR
First Name:STACY
Middle Name:M
Last Name:RAVIV
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1000 CENTRAL ST STE 615
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-1779
Mailing Address - Country:US
Mailing Address - Phone:847-570-2714
Mailing Address - Fax:847-733-5109
Practice Address - Street 1:1000 CENTRAL ST STE 615
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-1779
Practice Address - Country:US
Practice Address - Phone:847-570-2714
Practice Address - Fax:847-733-5109
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036113373207R00000X, 207RC0200X
IL036-113373207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine