Provider Demographics
NPI:1760402861
Name:RAVEILL, TIMOTHY G (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:G
Last Name:RAVEILL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9212 NIEMAN RD
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66214-1868
Mailing Address - Country:US
Mailing Address - Phone:913-599-6777
Mailing Address - Fax:913-599-3955
Practice Address - Street 1:2525 GLENN HENDREN DR
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:MO
Practice Address - Zip Code:64068-9625
Practice Address - Country:US
Practice Address - Phone:816-407-2038
Practice Address - Fax:816-792-7135
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20001658972085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
29296026OtherBCBS
29296026OtherBCBS
J01B027Medicare ID - Type Unspecified
MOJ04B027BMedicare PIN
MOW38B027Medicare PIN