Provider Demographics
NPI:1770689481
Name:RAVENSWOOD FAMILY MEDICINE CTR
Entity Type:Organization
Organization Name:RAVENSWOOD FAMILY MEDICINE CTR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ARIF
Authorized Official - Middle Name:M
Authorized Official - Last Name:MALIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-903-4579
Mailing Address - Street 1:PO BOX 325
Mailing Address - Street 2:
Mailing Address - City:RAVENSWOOD
Mailing Address - State:WV
Mailing Address - Zip Code:26164-0325
Mailing Address - Country:US
Mailing Address - Phone:304-273-4479
Mailing Address - Fax:304-273-2599
Practice Address - Street 1:316 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:RAVENSWOOD
Practice Address - State:WV
Practice Address - Zip Code:26164-1704
Practice Address - Country:US
Practice Address - Phone:304-273-2647
Practice Address - Fax:304-273-2636
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV19979207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV9350441Medicare PIN
WV9350442Medicare PIN