Provider Demographics
NPI:1851812721
Name:RAVENNA MEDICAL CLINIC PC
Entity Type:Organization
Organization Name:RAVENNA MEDICAL CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASSISTANT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:LIESKE
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:308-452-3203
Mailing Address - Street 1:611 W SENECA ST
Mailing Address - Street 2:
Mailing Address - City:RAVENNA
Mailing Address - State:NE
Mailing Address - Zip Code:68869-1200
Mailing Address - Country:US
Mailing Address - Phone:308-452-3203
Mailing Address - Fax:308-452-3795
Practice Address - Street 1:104 W SENECA ST
Practice Address - Street 2:
Practice Address - City:RAVENNA
Practice Address - State:NE
Practice Address - Zip Code:68869
Practice Address - Country:US
Practice Address - Phone:308-452-3203
Practice Address - Fax:308-452-3795
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-30
Last Update Date:2017-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health