Provider Demographics
NPI:1295773257
Name:FERNANDO RAVESSOUD, M.D. INC.
Entity type:Organization
Organization Name:FERNANDO RAVESSOUD, M.D. INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:FERNANDO
Authorized Official - Middle Name:
Authorized Official - Last Name:RAVESSOUD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-595-5424
Mailing Address - Street 1:3918 LONG BEACH BLVD
Mailing Address - Street 2:SUITE 180
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90807-2666
Mailing Address - Country:US
Mailing Address - Phone:562-595-5424
Mailing Address - Fax:562-595-8927
Practice Address - Street 1:3918 LONG BEACH BLVD
Practice Address - Street 2:SUITE 180
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90807-2666
Practice Address - Country:US
Practice Address - Phone:562-595-5424
Practice Address - Fax:562-595-8927
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-03
Last Update Date:2008-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA=========OtherTAX ID
CA=========OtherTAX ID
CAAW225ZMedicare PIN