1205863800 NPI number — DR. CAROLL ANN REVAK PH.D.

Table of content: DR. CAROLL ANN REVAK PH.D. (NPI 1205863800)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205863800 NPI number — DR. CAROLL ANN REVAK PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
REVAK
Provider First Name:
CAROLL
Provider Middle Name:
ANN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205863800
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 SAREDON PL
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
ROCHESTER
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14606-4070
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
585-426-8460
Provider Business Mailing Address Fax Number:
585-426-8460

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 SAREDON PL
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
ROCHESTER
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14606-4070
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
585-426-8460
Provider Business Practice Location Address Fax Number:
585-426-8460
Provider Enumeration Date:
06/27/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  007402-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100242FC . This is a "PREFERRED CARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 7700518 . This is a "DOCTOR'S HEALTH PLAN MVP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 7760102 . This is a "AETNA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".