Provider Demographics
NPI:1669498168
Name:SCOVILLE, RALPH DALTON (MD)
Entity Type:Individual
Prefix:DR
First Name:RALPH
Middle Name:DALTON
Last Name:SCOVILLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:NONE
Other - Middle Name:NONE
Other - Last Name:NONE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:626 REVOLUTION ST
Mailing Address - Street 2:
Mailing Address - City:HAVRE DE GRACE
Mailing Address - State:MD
Mailing Address - Zip Code:21078-3320
Mailing Address - Country:US
Mailing Address - Phone:410-939-8744
Mailing Address - Fax:443-502-2633
Practice Address - Street 1:626 REVOLUTION ST
Practice Address - Street 2:
Practice Address - City:HAVRE DE GRACE
Practice Address - State:MD
Practice Address - Zip Code:21078-3320
Practice Address - Country:US
Practice Address - Phone:410-939-8744
Practice Address - Fax:443-502-2633
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2013-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD153682084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD922801200Medicaid
MD922801200Medicaid