Provider Demographics
NPI:1609997055
Name:JOHN S. RAVITA MD PA
Entity Type:Organization
Organization Name:JOHN S. RAVITA MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF RADIATION MEDICINE
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:SALVATORE
Authorized Official - Last Name:RAVITA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:803-791-2598
Mailing Address - Street 1:104 WINDSONG ISLAND LN
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29212-8329
Mailing Address - Country:US
Mailing Address - Phone:803-791-2598
Mailing Address - Fax:803-791-2577
Practice Address - Street 1:2720 SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-4810
Practice Address - Country:US
Practice Address - Phone:803-791-2598
Practice Address - Fax:803-791-2577
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8174174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPA5958Medicaid
SC=========OtherEIN NUMBER
SCPA5958Medicaid